International Journal of Spine Surgery最新文献

Background: Traditional surgical prehabilitation emphasizes biomechanical conditioning. In a pain landscape shaped by opioid exposure, trauma histories, and psychosocial distress, this reductionist approach is insufficient.

Objective: To propose a multidimensional, whole-person framework for perioperative readiness that integrates neurobiological mechanisms with practical clinical and policy levers.

Framework: Five synergistic domains-biological, psychological, social, spiritual, and existential-address discrete readiness deficits linked to dopaminergic tone, central sensitization, stress reactivity, connection, and meaning. Each domain is mapped to mechanisms, evidence-based interventions (eg, physical therapy, cognitive behavioral therapy/screening, social support linkage, chaplaincy, reflective practices), and relevant billing structures (Current Procedural Terminology Healthcare Common Procedure Coding System, International Classification of Diseases, 10th Revision Z codes).

Implementation: The model operationalizes a deliverables-based pathway-screen → triage → targeted interventions → outcome tracking-monitoring pain, function, opioid exposure (morphine milligram equivalents), length of stay/readmissions, depression and anxiety (Paitent Health Questionnaire-4), and pain catastrophizing (Pain Catastrophizing Scale). It aligns with risk-adjusted payment models and can be embedded within enhanced recovery after surgery programs.

Clinical significance: Reframing prehabilitation as neurobiologically informed whole-person readiness provides a low-risk, nonpharmacological strategy to reduce suffering, improve engagement, enhance postoperative pain control and recovery, and decrease opioid reliance.

Level of evidence: 5 (Expert Opinion). This perspective integrates neurobiological and behavioral theory with policy and billing frameworks to enable hypothesis-generating implementation and outcomes research.

Background: Despite >$3.2 billion invested across >1,800 projects by NIH's HEAL Initiative, scalable solutions for chronic pain and opioid use disorder remain limited. Continued reliance on opioid-replacement therapies often suppresses reward circuitry without restoring its neurobiology.

Objective: To articulate a neurobiologically grounded, whole-person strategy that reframes perioperative pain management as dopaminergic restoration, and to propose pragmatic clinical and policy steps for translation.

Approach conceptual model: We synthesize evidence that chronic pain and addiction share hypodopaminergic mechanisms (Reward Deficiency Syndrome). We highlight precision nutraceuticals (amino-acid precursors + enkephalinase inhibitors) aimed at restoring dopamine homeostasis-especially in genetically vulnerable patients identified by the Genetic Addiction Risk Severity (GARS) test-and position them within ERAS 2.0 as adjuncts to peripheral analgesia. KEY POINTS/RECOMMENDATIONS: (1) Initiate dopaminergic repletion ~2 weeks preoperative to 4 weeks postoperative, layered with local anesthetic strategies. (2) Incorporate GARS-guided risk stratification and track MMEs, pain, function, mood/craving, LOS, and 90-day opioid persistence. (3) Prioritize multicenter pragmatic RCTs and registries with mechanistic endpoints. (4) Improve funding transparency and link HEAL-like investments to clinical outcomes dashboards.

Clinical significance: We challenge the clinical status quo and call on spine surgeons and pain specialists to integrate dopaminergic repletion protocols within a precision-prehabilitation framework that offers a low-risk, non-opioid pathway to reduce suffering, enhance recovery, and decrease opioid dependence in spine surgery.

Level of evidence: 5 (Expert Opinion). The model integrates neurobiology, early translational signals, and policy levers to guide hypothesis-generating implementation.

Diagnosis and management of musculoskeletal pain in the lower back, buttock, and hip can be complex due to the multilayered muscular anatomy in this region. Each structure or functional group (ie, hip abductors) may present as a local pain syndrome. Pain may arise from osseous, intra-articular, ligamentous, musculotendinous, myofascial, neural, or vascular sources. Diagnosis is challenging due to overlapping innervation and referred pain patterns, particularly sclerotomal referral from osseous and ligamentous structures. Effective treatment requires accurate diagnosis. A regionalized approach categorizing pain syndromes into 6 anatomic zones-above the iliac crest, the iliac crest, the lateral hip, the gluteal region, sciatic nerve related, and the ischial tuberosity-may improve diagnostic clarity and guide treatment. A regionalized, 6-zone framework for posterior buttock pain may enhance diagnostic accuracy and guide individualized management.

Background: Chronic low back pain (CLBP) is a leading cause of disability worldwide. Multifidus muscle dysfunction is increasingly recognized as a distinct contributor to mechanical CLBP. Restorative neurostimulation has emerged as a targeted therapy for this phenotype.

Methods: A systematic review and meta-analysis was conducted according to PRISMA guidelines. Databases searched included PubMed, Cochrane, and Web of Science for studies published between January 2013 and September 2025. Eligible studies evaluated implantable restorative neurostimulation in adults with CLBP and multifidus dysfunction. Data extraction included patient demographics, study design, pain, disability, and quality of life outcomes. Risk of bias was assessed using Cochrane and National Institutes of Health tools. The meta-analysis reported pooled mean differences at 1- and 4-year follow-up.

Results: Six studies (N = 650; 546 treated, 104 controls) met inclusion criteria. Restorative neurostimulation resulted in significant improvements in pain (Numerical Rating Scale/visual analog scale), disability (Oswestry Disability Index [ODI]), and quality of life (EQ-5D) at 1 and 4 years. The meta-analysis showed a pooled mean reduction in pain scores of 3.2 (±0.8) at 1 year and 4.1 (±2.1) at 4 years. EQ-5D improved by 0.200 (±0.043) at 1 year and 0.251 (±0.072) at 4 years. Pooled mean ODI improvement was 17.1 at 1 year and 23.0 at 4 years, exceeding minimally clinically important differences at both 1 and 4 years. Mechanistic studies demonstrated reversal of multifidus fibrosis and normalization of muscle spindle structure.

Conclusions: Restorative neurostimulation targeting multifidus dysfunction provides sustained, clinically meaningful improvements in pain, disability, and quality of life for patients with mechanical CLBP. Accurate phenotyping and use of International Classification of Diseases, 10th revision, code M62.85 enable targeted intervention. Further research should focus on comparative effectiveness, cost-effectiveness, and predictive biomarkers to optimize patient selection.

Background: Persistent concerns remain about the deleterious pathological effects of minimally invasive transannular puncture, such as occurs during discography and therapeutic intradiscal procedures. The objective of this study was to estimate the safety profile associated with fluoroscopically guided intradiscal delivery of nucleus pulposus (NP) allograft under clinical trial and real-world conditions.

Methods: This was a retrospective pooled analysis of adverse events (AEs) and clinical complaints captured from 4 different treatment populations (n = 392) and a database of commercial cases (n = 19,392 discs treated) with lumbar discogenic pain who underwent minimally invasive intradiscal NP allograft supplementation. All AEs were graded for severity as mild, moderate, or severe, and relatedness was judged as possibly, probably, or definitely. All serious AEs were adjudicated for outcome.

Results: There were 51 total AEs reported across all 4 clinical cohorts, and 6 AEs (12%) were judged to be related to the NP allograft product and the intradiscal procedure, with an additional 4 AEs (8%) related solely to the intradiscal procedure. None of the AEs was associated with infection (ie, discitis), neurological compromise, or escalation to surgical treatment. The product-attributable serious AE incidence was 0.26% (1/392). Of the commercial cases (n = 19,392 discs treated), no clinical AEs were reported from this cohort, with only 101 device complaints (0.521%) related primarily to delivery interface or packaging integrity.

Conclusions: Intradiscal NP allograft supplementation for symptomatic degenerative disc disease demonstrates a favorable safety profile. These findings serve to temper concerns about the risk of disc complications and accelerated degeneration following transannular puncture.

Clinical relevance: These findings validate that the NP allograft product and procedure have an exemplary safety profile. As a microinvasive, motion-preserving intervention, this procedure has the potential to bridge the therapeutic gap between conservative care and invasive spine surgery for patients suffering from discogenic back pain.

Level of evidence: 4:

Lumbar discectomy remains the most common surgical treatment for lumbar disc herniation, potentially providing quick pain relief for patients. However, while pain resolution is a key measure of short-term success, it does not guarantee long-term recovery. In patients with large annular defects (≥6 mm), the structural vulnerability left by discectomy predisposes patients to recurrent herniation, which can trigger a return of severe pain, diminished function, and the need for additional surgery. Revision surgeries for recurrent herniations are costly and are associated with a lower chance of positive patient outcomes compared with primary procedures.Bone-anchored annular closure devices aim to address the root structural cause of recurrent herniation by sealing the annular defect during discectomy to preserve disc integrity. Adding a bone-anchored annular closure device to discectomy reduces symptomatic reherniation and reoperation rates by more than 50%, prolonging pain-free intervals and improving quality of life. Patients treated with bone-anchored annular closure devices report low pain scores over long-term follow-up, faster return to work, and reduced opioid requirements.Cost-effectiveness analyses demonstrate that in patients with a large annular defect, bone-anchored annular closure devices achieve cost neutrality, or savings, within 2 to 5 years, with incremental cost-effectiveness ratios below accepted thresholds. By preventing the recurrence of lumbar herniation and the need for reoperation, bone-anchored annular closure technologies offer a clinically validated, economically prudent solution aligned with value-based care principles and durable, patient-centered success.

Background: Lumbar fusion eliminates motion at the operative level and is associated with altered load transfer and adjacent segment degeneration. Total joint replacement (TJR) of the lumbar spine is a motion segment reconstruction procedure performed via a bilateral transforaminal approach that allows direct neural decompression and replacement of both disc and facet function. This prospective investigational device exemption clinical trial compared TJR with a concurrent, propensity-score-weighted real-world evidence cohort treated with either instrumented transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody spine fusion (PLIF).

Methods: This multicenter investigational device exemption trial was conducted at 20 US sites. Patient-reported outcomes from 152 TJR subjects implanted with the MOTUS device were compared with 142 propensity score-weighted TLIF/PLIF controls. Lumbar-related disability was measured with the Oswestry Disability Index (ODI) and back and worst leg pain severity by a 100-mm visual analog scale (VAS). Minimal clinically important difference thresholds were ODI ≥ 15 points and VAS ≥ 20 mm; responder analyses were also conducted using ≥30% and substantial clinical benefit (≥50%) thresholds. Effect sizes were calculated using Cohen's d or h.

Results: Baseline characteristics were well balanced, and there were no statistically significant differences between study groups. At 12 months, mean ODI decreased by 45 points (71%) with TJR and 37 points (59%) with TLIF/PLIF. The adjusted between-group difference was 8.1 points (95% CI, 2.5-13.7; P = 0.005; Cohen's d = 0.39, small). VAS back and leg pain decreases were similar between groups, with no significant between-group differences. Minimal clinically important difference responder rates were high (>85%) for both procedures; the ≥30% ODI threshold favored TJR (90% vs 80%; P = 0.04).

Conclusions: Substantial decreases in back impairment and pain severity were realized in both study groups. However, longitudinal improvement in ODI significantly favored patients treated with TJR.

Clinical relevance: Lumbar TJR combines decompression with motion preservation in a single procedure, potentially offering an alternative to fusion in selected patients. The advantage of utilizing a standard posterior operative approach with TJR is that it allows for direct decompression of the neural elements prior to implant placement.

Level of evidence: 2b.

As the population ages and the incidence of spine surgeries increases, better solutions are needed for the challenges of adequate pain control and lengthy hospital stays, which often result from difficulty with controlling pain, managing complications, or coordinating post-hospitalization care services. Thus, there is an inherent need for ways to improve pain and time to discharge. Minimally invasive techniques aim to minimize tissue disruption and can decrease pain and accelerate recovery. However, these techniques are not indicated for all spine patients, and not all spine surgeons are adequately trained in such techniques, thus limiting generalizability. In contrast, Enhanced Recovery After Surgery (ERAS) has recently been adopted within spine surgery as an alternative management strategy to optimize patient outcomes. Enhanced recovery principles mitigate the surgical stress response through a series of evidence-based, perioperative interventions that have demonstrated success with reducing postoperative pain and complications, increasing ambulation, and shortening length of stay. While still in its infancy within spine surgery, there is ample evidence for the successful implementation of ERAS programs for numerous spine procedures. However, further randomized trials will likely be needed to support the continued application of ERAS within spine surgery.