New technologies and imaging, new instruments and minimally invasive access to the spine, and a new generation of surgical navigation systems have revolutionized complex spine surgery in the past 20 years, allowing the surgeon to work in an ever increasing challenging spine surgery environment with greater safety. Among the most challenging indications for resolving complex spine disease includes spinal infection, spinal tumour, and spinal trauma, which will have unique natural history, surgical indication and risk profile [2].

Even though incidence has dropped considerably, spinal infection remains a major problem in low and middle income countries and has a major incidence of pyogenic spondylodiscitis and tuberculous (Pott's) spine disease, which manifest themselves late with marked destruction, deformity or neurological deficit [3]. Commonly used treatments in the care of patient with a tumour of the spine, whether primary or metastatic, involve decompression/stabilisation and if appropriate, tumour debulking, all to preserve neurological function, often in the presence of a large burden of co-morbidities [4]. Fracture-dislocations of the spine and unstable ‘burst' fractures should be taken to surgery early to stabilise the bone and prevent further damage to the nervous system (mobility) [5].

While they are different surgically speaking as to pathophysiology, these three parameters have common principles of surgical decompression, stabilization and alignment of the spine, and are increasingly being managed in complex spine surgery units [6]. The face of complex spine surgery is now changing and excellent new technologies like intra-operative navigation, Robotic-assisted pedicle screw placement and powerful new protocols like "enhanced recovery after surgery" (ERAS) are emerging, but inexplicably, still haven't taken off in resource-limited societies like Pakistan [7].

Hence, given the scarcity of locally generated data for comparison between these three important indications involving complex spine surgery, this study seeks to assess the clinical presentation, surgical approach and post-surgical outcomes in patients undergoing complex spine surgery to elucidate areas that require enhancement in the current practice and future directions needed to guide this evolving subspecialty at tertiary care centers in the local setting of Pakistan.

Study Design and Setting It was a comparative, observational study in spine surgery units of three Tertiary Care Teaching Hospitals of Pakistan; the department of Neurosurgery Jinnah Postgraduate Medical Centre, Karachi, the Punjab Institute of Neurosciences Lahore. The data collection started in August 2025 and continuing up to January 2026. Ethical Approval Ethical approval for the study was obtained from the Institutional Ethical Review Committees of the participating hospitals prior to enrollment, in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all patients, or from their legal guardians in the case of minors, prior to inclusion. Inclusion Criteria ● Patients of all ages with radiographically and clinically diagnosed spine infection; spine tumour and spine trauma who are going for surgery ● Patients who need decompression and/or instrumented stabilization as needed by the spine surgical team. ● Ability to complete preoperative, operative and postoperative follow-up records for at least 6 months Exclusion Criteria ● Patients managed conservatively without surgical intervention. ● Isolated stable fractures of the spine – not for instrumentation – patients were excluded from the study ● Incomplete clinical, operative and follow-up data cases. Surgical Management Culture & histopathology finding was the reason to undergo surgical debridement of all infected disc/vertebral tissue along with instrumented stabilization (with or without anterior column reconstruction) in the infection group. In the tumour group a decompressive laminectomy or corpectomy with instrumentation stabilisation was undertaken as this was individualized for the tumour type and patient prognosis. Re-reduction of the fracture-dislocation and instrumented posterior (or combined) stabilization was performed for all the patients in this trauma group in accordance with the treatment principles of spinal trauma by considering the morphology of the fracture and neurological status. Outcome Measures Primary outcomes included rate of postoperative complications and postoperative neurological improvement (using a standard (Frankel Grade) scale). Secondary outcomes consisted of preop VAS pain scores, VAS pain scores at 6 weeks, 3 months and 6 months after surgery, in-hospital mortality, and operative time and intraoperative blood loss. Statistical Analysis SPSS version 26.0 was used for analyzing all the data. The data of the continuous variables were presented as the mean and standard deviation, and analyzed using one-way ANOVA among the three groups. Categorical data were presented as absolute numbers and percentage and compared using Chi-square test. Statistically significant results were defined as a p value < 0.05.

During the six month study period 92 patients with complex spine surgery were added to the study: 30 patients in the infection group, 28 patients in the tumor group and 34 patients in the trauma group.  The trauma group was  the youngest and the duration of symptoms was appreciably less than the tumor group due to the acute nature of traumatic spinal injury. All groups had more thoracic and thoracic/lumbar involvement than other areas. An overview of the baseline characteristics is given in Table 1.

The tumor group had significantly longer operative time (198.6 ± 40.1 minutes) and intraoperative blood loss (480 ± 110 mL) than the other groups (p < 0.001 for both) as shown in Table 2. The length of hospital stay was the longest in the infection group (14.2 ± 3.8 days), the shortest in the trauma group (9.4 ± 2.6 days, p = 0.008) and not different in other groups.

The numbers in neurological improvement group in patients with infection, tumor, and with trauma were respectively 73.3%, 64.3%, and 76.5% with no statistically significant difference (p = 0.412). Postoperative complication rates (20.0% vs. 25.0% vs. 14.7%, p = 0.487) and in-hospital mortality (3.3% vs. 7.1% vs. 2.9%, p = 0.812) were also comparable across groups. Mean VAS pain scores decreased gradually from baseline to 6-month follow-up in all three groups and were reduced the most soon after treatment in the trauma group, as shown in figure 1.

Table 1: Demographic and Clinical Characteristics at Baseline (n = 92).

Table 2: Shows the postoperative and operative outcomes across three groups (n=92)

While there were significant differences across each of the three groups of disease courses, patients who underwent all three types of spine surgery had comparable postoperative neurologic improvement and complication rates, and the benefit of progressive and clinically important pain relief in the first 6 postoperative days. Together with their findings, these results suggest that a complex spine surgery service, with a single team in charge of handling high volumes of this varied case mix is beneficial [6,8]. The significantly longer operative time and blood loss in the tumor group are likely due to the more extensive tumor decompressions and reconstructions that frequently are associated with surgery for spinal tumor surgery, such as vertebral body corpectomy or circumferential stabilization [4,9]. These results are similar to those of international series comparing spinal tumour surgery to more complicated spine surgery, and actually reinforce that careful pre-operative planning and blood conservation during surgery for spinal tumour are important [9]. This increased duration of hospitalization resulted in the infection group as the need for prolonged parenteral antimicrobial therapy, wound surveillance and staged reconstruction exist in many cases of infected spine especially in tuberculosis infected cases of spinal infection that remain commonplace in countries like Pakistan, where the burden of this infection remains high [3,10]. We performed a study in a tertiary hospital of Karachi, patients who underwent surgical treatment for tuberculous spine disease also had prolonged hospital stay with the major cause being combined medical and surgical treatment [11]. A comparable study from a spine unit managing spinal tuberculosis also detailed a longer stay in the spine unit of a hospital in Lahore than seen with patients with trauma surgery who underwent spinal stabilization surgery, but without a significant difference in neurological outcome between the two groups [12]. These similar rates of neurological improvement across groups are encouraging and suggest the possibility for important neurological recovery, not just for the more extensively studied population of trauma patients [5,13] but also if careful patient selection and technique proves applicable to all patients with complex spine pathologies. This progressive decline in pain score VAS also, however, shows that decompression/stabilisation is effective at providing longer pain relief, irrespective of underlying pathology for ALL three groups. In the near future, another concern for future directions includes intraoperative navigation and robotic-assisted pedicle screw placement, which have demonstrated excellent accuracy of instrumentation and decreased the amount of radiation exposure for surgical staff, and may be increasingly adopted as price of the equipment decreases [7,14]. Enhanced recovery after surgery (ERAS) can further reduce hospital stay and minimise complications, there is no doubt that this is feasible in any kind of complex spine surgery and certainly also in resource poor settings where with relatively little investments multimodal analgesia can be achieved, mobility might be enhanced and surgical care pathways can be standardised [15]. Further advances in the development of invasive and endoscopic surgery for spinal infection and certain tumor types may decrease morbidity for surgery. There are the following limitations of this study. This is an observational study and therefore direct causal comparisons between each of the pathology groups should be undertaken with a cautious focus and taking into account the different biology of each group. The study time of 6 months is thus not long enough to provide functional and oncologic outcomes, in particular for the tumour group. Larger, multi-center studies with longer follow-up are needed to further explore long-term outcomes and the role of new technologies, such as navigation and robotics in this population.

The distinctiveness of the timing and nature of disease mean that the operative burden of the three groups (spinal infection, tumor surgery, and trauma) are quite different, but there are broadly comparable rates of neurological improvement and postoperative complications with complex spine surgery and progressive and meaningful pain relief in all three groups. An increased operative time and blood loss are associated with spinal tumor surgery, and a longer hospital stay is associated with spinal infection, which requires longer medical management. This data is used to argue in favour of the further development of adequately resourced complex spine surgery services at tertiary care centres, which can deal with this variety of surgical cases. In the future, there are many exciting aspects to be explored, including intraoperative navigation, robotic-assisted instrumentation, further enhanced recovery and less invasive surgery, which will all continue to improve outcomes and reduce resource utilization in complex spine surgery and, therefore should be perceived as priorities for further development and implementation with continued growth and development of expertise and facilities.

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