Here is a blog-ready summary of Dr. Rasouli’s Virtual Global Spine Conference lecture:

Post-Operative Evaluation of the Spine: A Practical Framework

Overview

In this February 2026 Virtual Global Spine Conference lecture , Dr. Jonathan J. Rasouli presents a structured, clinician-focused framework for interpreting post-operative spinal imaging — covering everything from the immediate post-operative period to delayed complications years down the line. While the content is accessible to trainees, it offers nuanced, experience-based insights that are equally valuable for practicing surgeons.

Immediate Post-Op Imaging (First Week)

The primary question in early post-operative imaging is simple: were the goals of surgery met? This includes confirming adequate neural decompression, verifying instrumentation at the correct levels, and assessing hardware positioning. Dr. Rasouli strongly advocates for thorough intraoperative fluoroscopy and stresses that a misplaced screw or loose construct should be a “never event” before leaving the OR .

He presents several instructive cases:

• A patient with residual cauda equina compression after L5-S1 discectomy whose post-op MRI revealed a residual fragment still compressing nerve roots

• A catastrophic construct failure due to insufficiently tightened screws and rods — visible on plain X-ray

• An anteriorly malpositioned cervical corpectomy cage (without posterior instrumentation) that progressed to anterior migration and acute quadriplegia

• A medially and inferiorly misplaced pedicle screw causing post-operative radiculopathy — identified on CT

The key lesson: early identification allows early revision, which is significantly easier than re-operating on a healed, scarred spine months later .

The MRI Dilemma: When Routine Becomes Risky

One of the lecture’s most clinically relevant points is the hazard of routine immediate post-operative MRI. Seromas and small hematomas are a normal part of post-surgical healing and can appear frankly compressive on MRI — even in completely asymptomatic patients . A study cited by Dr. Rasouli found that approximately 20% of asymptomatic post-operative patients have seromas that appear compressive on MRI, a rate that climbs even higher when BMP is used .

The dilemma this creates is real: if a radiologist flags a “compressive hematoma” in an asymptomatic patient, you are now faced with a documentation and decision-making problem — do you take the patient back preemptively or observe? His recommendation is clear: do not obtain routine MRI or CT post-operatively without clinical indication . If you do order it, have a pre-defined management plan for incidental findings before the results return .

The exception is firm: any patient with a new neurological deficit, unexplained pain, or clinical deterioration must be imaged promptly, including MRI and/or CT — and acted upon while the window for easy revision is still open .

The Non-Negotiable: Upright Standing X-Rays

A central theme of the lecture is the irreplaceable value of weight-bearing radiographs . CT and MRI are acquired supine, meaning spinal alignment, sagittal balance, and junctional problems may be entirely invisible or misleading. Dr. Rasouli illustrates this with a patient whose MRI was completely clean — no compressive pathology, patent nerve roots — yet whose full-spine standing X-ray clearly revealed a high thoracic proximal junctional kyphosis (PJK) that explained all their symptoms .

His rule of thumb: always pair cross-sectional imaging with a standing scoliosis X-ray. In complex deformity patients, this single film often tells you more than any other modality .

Delayed Complications: Alignment, Fusion, and Adjacent Segments

In the weeks-to-years phase, the focus shifts to three major questions :

1. Is the patient in proper alignment?

2. Was a solid fusion achieved, or is pseudarthrosis developing?

3. Are there delayed complications — PJK/PJF, distal junctional failure, or adjacent segment disease (ASD)?

Proximal & Distal Junctional Kyphosis/Failure

PJK and PJF are among the most common and consequential delayed complications following long-segment fusions . Radiologists often report “hardware intact, no hardware failure” — technically accurate, but missing the alignment failure entirely . Dr. Rasouli presents multiple cases of T10-to-pelvis constructs with upper thoracic PJK at T2–T4 levels — describing them as among the most surgically challenging revisions in all of spine surgery . These patients frequently cycle through pain management and physical therapy for years before the structural problem is identified and addressed.

Early signs typically appear around the 6-month mark post-operatively, and prompt identification allows for less complex revision surgery .

Pseudarthrosis After Cervical Fusion

For patients presenting with persistent neck pain after ACDF, pseudarthrosis is Dr. Rasouli’s primary concern until proven otherwise . His evaluation protocol combines:

• CT cervical spine to assess for bony bridging

• Flexion-extension X-rays with zoomed analysis of interspinous distance — a method he describes as more sensitive than CT for detecting motion at the fused level

Regarding treatment, the pendulum has swung toward posterior cervical fusion as the preferred revision strategy for anterior cervical pseudarthrosis, supported by institutional data showing better outcomes compared to anterior revision alone .

Key Takeaways for Clinical Practice

The overarching message of the lecture is that a radiologist’s report is a starting point, not a conclusion . Spine surgeons must read their own imaging with alignment, fusion, and biomechanical context in mind — because the findings that matter most (PJK, sagittal imbalance, pseudarthrosis) are often invisible to those without surgical training.