With the development of medical fundamentals, related disciplines and industrial technology, many basic concepts, diagnostic criteria, treatment concepts and therapeutic approaches in the field of spinal surgery have been continuously improved. In particular, over the past 20 years, the level of diagnostic and therapeutic advances in spine surgery has been very encouraging, such as 3D CT and MRI, which treat the human body like a transparent body; the clinical application of C-arm fluoroscopy, navigators, endoscopes, various spinal surgical tools and built-in objects, which have led to satisfactory clinical results in the surgical treatment of difficult diseases such as upper cervical spine, scoliosis and spinal tumors. Therefore, with the widespread use of numerous spinal surgical devices, equipment and surgical techniques, the development of new techniques for spinal surgical treatment has become a common concern in the orthopedic community. This article briefly reviews the progress and development trend of spinal surgery in recent years from the following aspects, hoping to encourage each other with our spinal surgery colleagues and jointly promote the development of spinal surgery in China. I. Surgical treatment of atlantoaxial dislocation Atlantoaxial dislocation refers to the loss of normal alignment of the atlantoaxial and pivotal articular surfaces caused by trauma, congenital malformation, degeneration, tumor, infection and inflammation or surgery, resulting in joint and/or neurological dysfunction. Because of the complex anatomy of the atlantoaxial spine and the many important nerves and blood vessels surrounding it, surgical treatment of this area is difficult and risky, making it a “danger zone” for surgical procedures. In addition, the atlantoaxial spine is the most mobile segment of the cervical spine, and its rotational range of motion accounts for more than 50% of the entire cervical rotational range of motion (120°-160°). Therefore, the principle of selecting the surgical procedure for severe atlantoaxial subluxation is of great importance to the safety and efficacy of its treatment. In the past decade, basic and clinical research on atlantoaxial dislocation in China has progressed rapidly, such as: anterior transoral atlantoaxial lesion removal, canal decompression and screw plate internal fixation; anterior transoral or endoscopic release of anterior atlantoaxial contracture and posterior atlantoaxial screw repositioning and fixation technique; anterior transaxial atlantoaxial joint lateral block screw fixation and fusion; posterior transaxial atlantoaxial joint lateral block screw fixation and fusion ( Magerl technique); atlantoaxial plate clamps (Appofix clamps), titanium cable fixation fusion; and various posterior nail plate and rod internal fixation systems have been carried out in many hospitals in China. Among them, the atlantoaxial pedicle screw repositioning and fixation technique, which was first reported by China-Japan Friendship Hospital in 2002, has been particularly effective in treating severe C1-C2 dislocations with oral or endoscopic release of contracted tissue in the anterior atlantoaxial spine. It is well known that in cases of severe C1-C2 dislocation, the cervical longus and capsular ligaments in front of the joint gradually contract, scar formation, and deformation of the lateral block joint or malunion of the odontoid fracture heal, resulting in anterior displacement of C1 and the head and forward shift of the center of gravity of the head, forming a posterior convexity of the upper cervical spine and anterior convexity of the lower cervical spine, which is known as gooseneck deformity. At the same time, the anterior displacement of the atlantoaxial vertebra and the superior end of the dentate or pivotal vertebral body are displaced relatively posteriorly and superiorly, causing severe compression of the ventral aspect of the medulla oblongata and severe compression of the posterior aspect of the medulla oblongata by the posterior arch of C1 and the posterior border of the foramen magnum, and this type of dislocation cannot be reset by cranial traction. The traditional view is that this type of dislocation should not be repositioned surgically to avoid aggravating spinal cord injury and vertebral artery blood supply disorder. Therefore, transoral resection of the odontoid process for anterior decompression, additional posterior decompression, and in situ occipitocervical fixation and fusion are mostly used. This traditional method cannot correct C1-2 dislocation, and the improvement of spinal cord function is unsatisfactory. Moreover, transoral decompression surgery is difficult to operate, with high incidence of serious complications such as cerebrospinal fluid leakage, subarachnoid infection, and spinal cord injury, and high surgical mortality. In addition, the need for fixation of fused cervical occipital segments 4-5 severely restricts head and neck movement. Advantages of the new surgery: 1. Intraoperative reset and firm fixation: the atlantoaxial pedicle screw plate internal fixation technique can effectively reset C1-2 dislocation during surgery, even to anatomical reset and release spinal cord compression. 2.Safety: Only soft tissue release in front of the atlantoaxial spine is done, and the odontoid process is not removed, which greatly simplifies the complexity of the operation and shortens the operation time, and can reduce spinal cord injury and cerebrospinal infection, paraplegia or mortality to the level of conventional spinal surgery. 3.Short segment fixation: only the atlantoaxial spine is fixed, which can preserve more cervical movement function. In recent years, many authors at home and abroad, such as Curier, Goel, Harms, Tan Mingsheng, Wang Chao, Yin Qingshui, Hao Dingjun, School Baiping, and many medical schools in China have used the above method to treat more than 500 cases of irreducible C1-C2 dislocation, and the results show that this method is safe, can obtain satisfactory repositioning, release spinal cord compression, correct C1-C2 kyphosis deformity, establish stable osseous fusion, and significantly reduced surgical complications. The treatment method of transoral release repositioning and strong internal fixation is a bold exploration, which has achieved better results and deserves further study. Second, spinal cord trauma Many scholars advocate early surgery for thoracolumbar burst fracture to restore the canal diameter of the spinal canal, release the spinal cord compression and rebuild the stability of the spine. However, the degree of protrusion of bone fragments into the spinal canal on imaging does not correspond to the severity of nerve damage symptoms, and some studies have found no significant difference between the effects of non-operative and operative treatment of burst fractures without spinal cord injury. The choice of surgical access for spinal fracture dislocation is also controversial, and generally the surgical access is mostly chosen according to the source of spinal cord compression and the time after injury: compression originates from larger bone blocks in front of the spinal canal, and anterior decompression is chosen. for fresh fractures within 2-3 weeks, most can be propped up by a posterior arch root internal fixation system to indirectly reset the compressed vertebrae and achieve spinal canal decompression. In recent years, there has been no significant change in the concept of internal fixation, which is limited to the improvement of the internal fixation system, mainly to reduce the incision of the internal fixation and to facilitate the operation. There are many different types of internal fixation for spinal stability reconstruction, and each type of internal fixation has its own advantages and disadvantages for spinal fracture and dislocation surgery, and should be chosen carefully. There is no effective treatment for spinal cord injury (SCI). Early repositioning of fracture dislocations and surgical release of spinal cord compression are the main measures to maximize preservation and restoration of residual spinal cord function, but the timing of surgery is still highly controversial. Current research on the treatment of spinal cord injury is focused on both protection and repair. Spinal cord protection is the application of various drugs to inhibit and reduce secondary damage in the early stages of injury. A US National Acute Spinal Cord Injury Study reported the results of a clinical trial of mega-dose methylprednisolone for acute spinal cord injury. Patients who received intravenous infusions of methylprednisolone within 8 hours of injury showed significantly stronger improvements in motor function and pinprick and tactile sensation at 6 weeks and 6 months post-injury than controls. Interestingly the infusion of methylprednisolone after 8 hours of injury seemed to be of little significance. Although high doses of methylprednisolone may reduce secondary damage to the spinal cord, there is also a potential increased risk of wound infection and gastrointestinal bleeding as a side effect of high dose application of steroid therapy for up to 24 hours. Drugs to promote recovery from acute spinal cord trauma are being investigated, and some spinal cord injury centers are studying the effects of using GM-1 ganglioside, naloxone (an opioid antagonist), and monosialate ganglioside (Sygen) to stimulate nerve regeneration. These drugs are thought to be beneficial in the treatment of acute spinal cord injury, but the results of experimental protocols vary widely and the translation of animal test results to clinical practice is difficult. Experimental studies on spinal cord injury repair have focused on both nerve grafting and gene therapy, and although many experimental studies have been reported, they are still a long way from clinical application. Third, degenerative spinal diseases The initiating factor of degenerative spinal degeneration originates from the intervertebral disc. Biomechanical studies have shown that when the intervertebral space is degenerated and narrowed, the pressure on the small joints increases significantly, producing abnormal stress and abnormal motion, followed by osteophytes of the small joints and compensatory hypertrophy of the ligaments, which are the important pathological basis for clinical symptoms. Currently, the treatment of degenerative spinal disease focuses on symptom relief through decompression of the spinal cord and nerve roots, but surgery may affect the stability of the spine. Spinal fusion is the traditional method for reconstructing chronic lower back pain due to lumbar degeneration instability, and it is similar to arthrofusion of the hip or knee. Because joint fusion will result in loss of function of the corresponding joint, it is no longer used as routine treatment. In the case of spinal fusion, only some segments are fused and their overall function is less affected, and the success rate of the procedure is higher. In recent years, with the development of fusion techniques, the fusion rate has approached 100%, but this figure does not reflect clinical outcomes. Recent literature has called into question the efficacy of spinal fusion for the treatment of lower back pain. In addition, the aggravation of degeneration of adjacent segments after fusion is an important complication. However, spinal fusion remains the primary treatment for degenerative instability at this time. The treatment of degenerative spinal disease focuses on restoring neurological and spinal function. Degeneration of the intervertebral discs leads to narrowing of the intervertebral spaces, smaller intervertebral foramina and increased small joint loading, resulting in altered biomechanical function of the spine. In order to maintain the height of the intervertebral space, maintain the stability of the spine, and maximize the restoration of spinal function, various non-fusion procedures of the lumbar spine, such as artificial discs, artificial nuclei, and spinal stability reconstruction techniques such as X-STOP, Graf, and Dynesys posterior spinal elastic fixation systems, have been used in Europe and some Asian countries since 1990 to treat young people, athletes, and patients with multi-segmental It is clear that fusion surgery is not suitable for such patients, and that non-fusion surgery would be ideal. To date, there have been tens of thousands of successful cases with more than ten years of clinical trials and follow-up, with good short-term results, but the overall success rate is still inferior to that of hip and knee fusion, and further clinical studies are needed. The treatment of single-segment spinal cord cervical spondylosis is less controversial, while the use of anterior or posterior treatment for multi-segment cervical spondylosis is still more controversial. In addition, the use of internal fixation in the treatment of cervical spondylosis is controversial, and there is no consensus on the timing of surgical intervention. There are many types of spinal deformities, and a representative deformity is idiopathic scoliosis, which is a deformity that includes various pathological changes of spinal deformities. There are still many problems in the correction of scoliosis with three-dimensional deformities. Extensive biomechanical studies of the spine have provided sufficient theoretical basis for the design of spinal endoprostheses, the basic principle of which is that the spine is composed of intervertebral disc “joints” and small joints on both sides of the posterior column. Therefore, adjustable endophysiology in the segmental three-dimensional space is necessary to adapt to the anatomical and physiological characteristics of the spine. The clinical application of devices represented by the Cotrel-Dubousset segmental endoprosthesis (CD) system has achieved three-dimensional deformity correction of scoliosis and further improved the treatment outcome of scoliosis. However, the early CD systems were complicated in operation, difficult in device and high in incision. At present, such as Isola, MossMiami, H, CDH and a variety of domestic improved three-dimensional orthopedic systems have appeared at home and abroad and have been widely used in the field of scoliosis. However, there are still many issues that need to be addressed to make scoliosis truly three-dimensional orthopedic, maintenance of fixation, and eventual bony fusion. The deformity of scoliosis is a very complex and dynamic deformity that continues to develop as the body develops. Therefore, the treatment of scoliosis, as well as the timing of surgery, the selection of fusion segments, and the prevention of complications, remain controversial. In order to standardize and systematize the treatment of scoliosis, the previous staging of idiopathic scoliosis has followed the foreign staging. The more common and accepted typing method at home and abroad is the King typing, but this typing system is not comprehensive, and there are many problems in clinical application, such as loss of compensation. The PUMC typing was proposed in the hope of providing a clinical standard for the surgical treatment of idiopathic scoliosis that is consistent with the three-dimensional orthopaedic approach in China. With the continuous improvement of spinal surgical orthopaedic techniques and the increase in the number of surgeries, the problems brought about by surgery have been clinically found to be increasing. Therefore, the natural history and non-surgical treatment of adolescent idiopathic scoliosis has regained the attention of the orthopaedic community. There has been an increase in the number of clinical studies reporting orthopedic bracing as an effective treatment for adolescent idiopathic scoliosis, with indications for soft scoliosis of 20°-30° in the growth phase and with data demonstrating an increase in scoliosis of 5° or more in sick children. Treatment of children with 30°-40° scoliosis in the growth phase should be initiated at the time of initial diagnosis. Although 40°-50° scoliosis in children in the growth phase is usually amenable to surgical treatment, bracing should be considered for some scoliosis, such as double-arc scoliosis with an acceptable profile of 40°-50°. Bracing should not be used in patients with scoliosis above 50°. It is hoped that clinicians will treat brace therapy correctly. V. Minimally invasive techniques Since the application of minimally invasive techniques in orthopedics, advanced computer technology and visualization techniques have been widely used in the field of spinal surgery. Through medical imaging such as digital X-ray, 3D reconstructed CT and MRI, the structure of the surgical area can be oriented and positioned in three dimensions, for example, the orthopedic 3D directional navigation system can guide and evaluate the physician’s surgical operation, which can not only improve the accuracy of internal fixation device placement, but also reduce the trauma of surgical incision exposure and improve the safety of surgery. However, its operation is cumbersome, expensive and not yet popular. With the development of optical and electromechanical technology, endoscopic minimally invasive surgery became an important role in various surgical procedures at the end of this century, and some of them even completely replaced traditional incisional surgery and became the main role in surgical procedures. For example, in the 1980s, percutaneous puncture disc aspiration, PLDD and radiofrequency ablation disc decompression; in the mid-1990s, the spinal endoscope was introduced and equipped with fine 2.7mm diameter nucleus pulposus forceps, planing knives and other surgical instruments, making blind disc decompression surgery into direct vision surgery; MED surgery was introduced into China in 1999 and rapidly promoted until early 2003. MED has the characteristics of minimally invasive, effective and easy to grasp, and the excellent rate is more than 90% within 1 year after surgery, however, there are still some problems with this technology that should attract our attention. With the arrival of an aging population, osteoporotic spinal fractures have become a serious threat to public health. In patients with non-root intractable pain due to spinal compression fractures, recent percutaneous vertebroplasty (PercutaneousVertebroplasty), kyphoplasty and (SKY) can significantly reduce pain symptoms, rebuild spinal stability, partially restore vertebral height, improve patients’ quality of life, and reduce patients’ long-term bedridden or complications associated with open surgery. Minimally invasive or non-invasive treatment is the ideal realm pursued by surgeons, but it must be treated seriously with a scientific attitude. One must fully understand the indications for various minimally innovative techniques and not blindly pursue small incisions and hastily deny the advantages of traditional open surgery. Minimally invasive techniques must conform to the principles of less trauma, better efficacy, and faster recovery, and it is the direction of development of spinal surgery. However, the field of spine surgery is far from being limited to this, and we hope that the above insights will trigger in-depth thinking among the majority of spine surgeons.