International Journal of Spine Surgery最新文献

Objective: To investigate the impact of dietary management on postoperative swallowing care of patients undergoing anterior cervical surgery.

Methods: This prospective randomized controlled trial involved 120 patients who underwent anterior cervical surgery in the orthopedic department of a tertiary hospital from March 2022 to March 2023. Patients were randomly divided into observation and control groups (n = 60 each). The control group received routine postoperative care, whereas the observation group received additional systematic dietary management intervention. The outcome measures comprised recovery time of swallowing function, Repetitive Saliva Swallowing Test (RSST) scores, Swallowing Quality of Life (SWAL-QOL) scores, nutritional status, and patient satisfaction.

Results: The observation group showed a shorter recovery time of swallowing function than the control group (8.6 ± 2.3 vs 13.5 ± 3.7 days; t = 8.475, P < 0.01). At 3, 7, and 14 days after surgery, both the RSST and the SWAL-QOL scores were higher in the observation group than in the control group (P < 0.01). At 14 days after surgery, the Nutrition Risk Screening 2002 score was lower in the observation group (1.8 ± 0.6 vs 2.5 ± 0.8, t = 5.387, P < 0.05). By contrast, serum albumin levels were higher in the observation group (38.6 ± 3.1 g/L vs 35.7 ± 3.4 g/L, t = 4.962, P < 0.05). Patient satisfaction scores were higher in the observation group than in the control group (87.6 ± 6.8 vs 72.3 ± 8.5; t = 11.026, P < 0.001).

Conclusion: Systematic dietary management effectively promotes the recovery of swallowing function, improves nutritional status, and increases patient satisfaction after anterior cervical surgery, supporting its clinical application.

Clinical relevance: Systematic dietary management provides a practical, evidence-based intervention to address postoperative dysphagia in anterior cervical surgery patients. This approach can be readily implemented in clinical settings to accelerate functional recovery, reduce nutritional complications, and improve patient outcomes. The graded dietary protocol and assessment tools (RSST and SWAL-QOL) offer health care teams standardized methods for managing swallowing dysfunction, ultimately enhancing perioperative care quality.

Level of evidence: 2:

Cerebrospinal fluid (CSF) leaks of spinal origin present unique diagnostic and therapeutic challenges. Ventral leaks in particular are technically demanding due to limited exposure, proximity to the spinal cord, and the need for precise dural repair. Traditional management strategies, ranging from laminectomy-based approaches to thoracotomy, carry significant morbidity. Recent advances in full endoscopic spine surgery provide a minimally invasive alternative that allows surgeons to access ventral pathology, remove osteophytes, and perform direct dural closure under continuous irrigation. This article reviews treatment challenges, highlights conventional and emerging strategies, and discusses the role of full endoscopic repair of spinal CSF leaks. Technical considerations unique to endoscopic repair of Type 1 CSF leaks in the thoracic spine are described.

Background: A lumbar disc herniation is the primary cause of sciatica, affecting 1% to 5% of the population annually. Epidural corticosteroid injections, whether via the transforaminal or interlaminar route, are an option for patients with refractory sciatica pain. The transforaminal route has the advantage of directly addressing the site of pathology in the anterior epidural space, between the disc herniation and the nerve root.

Purpose: To evaluate the efficacy of transforaminal infraneural epidural injections using corticosteroids in the treatment of radiculopathy secondary to acute lumbar disc herniation.

Study design: Descriptive, nonrandomized, retrospective, and uncontrolled single-center study.

Patient sample: Patients with radiculopathy secondary to acute lumbar disc herniation who underwent transforaminal epidural infiltrations between 2022 and 2024 were included.

Main outcome measures: Efficacy of transforaminal infraneural epidural injections using corticosteroids in the treatment of radiculopathy secondary to acute lumbar disc herniation.

Methods: The inclusion criteria were (1) patients with onset of radiculopathy symptoms in the lower limbs less than 12 weeks prior; (2) patients with persistent radiculopathy symptoms in the lower limbs for more than 8 weeks; (3) clinical signs and symptoms of radiculopathy; (4) lumbar spine magnetic resonance imaging showing discopathy compatible with the clinical examination; and (5) minimum age of 18 years. From a technical standpoint, the entire procedure was performed in the operating room with sedation and local anesthesia.

Conclusions: Radicular blocks are minimally invasive forms of treatment for radiculopathy refractory to medication-based analgesia due to an acute lumbar disc herniation. Transforaminal blocks offer the advantage of providing analgesia with a smaller amount of corticosteroid and represent a nonsurgical alternative that appears to be effective in treating radiculopathy secondary to acute lumbar disc herniation.

Clinical relevance: This study highlights that infraneural transforaminal epidural steroid injection provides effective analgesia for acute lumbar radiculopathy secondary to disc herniation while using a smaller corticosteroid dose. This approach may help reduce systemic exposure and procedural risks, offering a safer alternative for patients requiring minimally invasive pain management.

Level of evidence: 3:

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.

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: 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.

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.