The role of spinal surgery in the treatment of low back pain

Lumbar spine fusion surgery versus best conservative care for patients with severe, persistent low back pain

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians' views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Methods

An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials.

Results

There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%).

Conclusion

This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK.

The Sanbi Decoction alleviates intervertebral disc degeneration in rats through intestinal flora and serum metabolic homeostasis modulation

BACKGROUND

Intervertebral disc degeneration (IVDD) is an essential cause of low back pain (LBP), the incidence of which has risen in recent years and is progressively younger, but treatment options are limited, placing a serious economic burden on society. Sanbi decoction (SBD) is an important classical formula for the treatment of IVDD, which can significantly improve patients' symptoms and is a promising alternative therapy.

PURPOSE

The aim of this study is to investigate the safety and efficacy of SBD in the treatment of IVDD and to explore the underlying mechanisms by using an integrated analytical approach of microbiomics and serum metabolomics, as well as by using molecular biology.

METHODS

A rat IVDD puncture model was established and treated by gavage with different concentrations of SBD, and clean faeces, serum, liver, kidney, and intervertebral disc (IVD) were collected after 4 weeks. We assessed the safety by liver and kidney weighing, functional tests and tissue staining, the expression of tumor necrosis factor-alpha (TNF-ɑ), interleukin 1β (IL-1β) and interleukin 6 (IL-6) inflammatory factors in serum was detected by ELISA kits, and X-ray test, magnetic resonance imaging (MRI) examination, immunohistochemistry (IHC), western blotting (WB), hematoxylin-eosin (HE) staining and safranin O-fast green (SO/FG) staining were used to assess the efficacy. Finally, we performed 16S rRNA sequencing analysis on the faeces of different groups and untargeted metabolomics on serum and analyzed the association between them.

RESULTS

SBD can effectively reduce the inflammatory response, regulate the metabolic balance of extracellular matrix (ECM), improve symptoms, and restore IVD function. In addition, SBD can significantly improve the diversity of intestinal flora and maintain the balance. At the phylum level, SBD greatly increased the relative abundance of Patescibacteria and Actinobacteriota and decreased the relative abundance of Bacteroidota. At the genus level, SBD significantly increased the relative abundance of Clostridia_UCG-014, Enterorhabdus, and Adlercreutzia, and decreased the relative abundance of Ruminococcaceae_UCG-005 (p < 0.05). Untargeted metabolomics indicated that SBD significantly improved serum metabolites and altered serum expression of 4alpha-phorbol 12,13-didecanoate (4alphaPDD), euscaphic acid (EA), alpha-muricholic acid (α-MCA), 5-hydroxyindoleacetic acid (5-HIAA), and kynurenine (Kyn) (p < 0.05), and the metabolic pathways were mainly lipid metabolism and amino acid metabolism.

CONCLUSIONS

This study demonstrated that SBD can extensively regulate intestinal flora and serum metabolic homeostasis to reduce inflammatory response, inhibit the degradation of ECM, restore IVD height and water content to achieve apparent therapeutic effect for IVDD.

Preoperative opioid use and postoperative return to work following spinal surgery in workers' compensation settings: a systematic review and meta-analysis

BACKGROUND

Opioid use prior to spinal surgery is common among patients with workers' compensation (WC) claims. Extended opioid use for pain management in this population is associated with several adverse outcomes including delayed return to work (RTW).

OBJECTIVE

This systematic review and meta-analysis aim to assess the evidence on the association of preoperative opioid use with stable RTW and RTW within 1-year after spinal surgery.

MATERIAL AND METHODS

The authors searched MEDLINE, Embase, PsycINFO, Emcare, CINAHL Plus, Scopus, and Web of Science from inception to 14 January 2023. The authors included studies that compared any preoperative opioid use with no opioid use, and those that enabled a comparison of different durations of preoperative opioid use. The primary outcome was stable RTW after spinal surgery. Secondary outcomes were RTW within 1-year after surgery and cost of WC claims. A random effect model was assumed to pool the effect estimate. The GRADE approach was applied to evaluate the certainty of evidence.

RESULTS

From 2589 records, 10 studies were included, and of these, nine were considered for quantitative synthesis. All studies were observational with eight retrospective cohort and two case-control studies. Five studies each investigated cervical and lumbar disorders. With moderate certainty evidence, the odds of postoperative stable RTW reduced by half (OR: 0.51, 95% CI: 0.43-0.59; 5549 participants) in patients using opioids preoperatively. Similarly, moderate certainty evidence from 2348 participants demonstrated that the odds of RTW within 1-year after surgery were reduced by more than half in patients with preoperative opioid prescriptions (OR: 0.46, 95% CI: 0.36-0.59).

CONCLUSIONS

This systematic review and meta-analysis shows that preoperative opioid use is associated with a reduction in odds of postoperative RTW by half in patients with WC-funded spinal surgery.

Multimodal management strategies for chronic pain after spinal surgery: a comprehensive review

"Chronic pain after spinal surgery" (CPSS) is a nonspecific term for cases in which the end result of surgery generally does not meet the preoperative expectations of the patient and surgeon. This term has replaced the previous term i.e., failed back surgery syndrome. CPSS is challenging for both patients and doctors. Despite advancements in surgical techniques and technologies, a subset of patients continue to experience persistent or recurrent pain postoperatively. This review provides an overview of the multimodal management for CPSS, ranging from conservative management to revision surgery. Drawing on recent research and clinical experience, we aimed to offer insights into the diverse strategies available to improve the quality of life of CPSS patients.

Quality of Life, Disability Level, and Pain Intensity among Patients after Lumbar Disc Surgery: An Observational Three-Month Follow-Up Study

The prevalence of intervertebral disc degeneration in the lumbar region resulting in low back pain is high. One of the treatment options is neurosurgery. Previous studies and systematic reviews demonstrate the need to identify factors that affect the health-related quality of life of patients undergoing surgery. This study aimed to analyze the sociodemographic and clinical factors that affect the quality of life of patients undergoing lumbar disc surgery. A group of 128 patients was assessed for eligibility and qualified by radiological examinations for lumbar disc surgery by a neurosurgeon in the outpatient clinic. Finally, 110 patients were studied and evaluated 24 h and 3 months after surgery. Health-related quality of life (36-Item Short Form Survey, SF-36), disability level (Oswestry Disability Index, ODI), and pain intensity (Visual Analogue Scale, VAS) were assessed. The mean pain intensity before surgery was 7.8 ± 2.3 pts and decreased significantly 24 h after surgery, with a mean score of 3.8 ± 2.4 pts (p = 0.0000). After three months, the increase in pain intensity was at 4.8 ± 2.4 pts, but the score was still significantly better than before surgery (p = 0.0024). The mean ODI score before surgery was 29.3 ± 8.4 pts (slight disability), and three months after surgery, there was an insignificant increase to a mean value of 31.5 ± 10.4 pts (p = 0.0834). There was a statistically significant increase in quality-of-life scores at three months after surgery in the following domains: physical functioning (8.7%; p = 0.0176), bodily pain (26.2%; p = 0.0000), vitality (5.8%; p = 0.0132) and mental health (6.2%; p = 0.0163), and a decrease in role limitations due to physical problems (3.8; p = 0.0013) and general health perception (6.7%; p = 0.0112). In conclusion, the surgical procedure plays an important role in improving the quality of life of patients operated on for intervertebral disc degeneration. It was effective in reducing the pain level, especially 24 h after surgery; however, surgery did not affect the disability level.

Elective spinal surgery in New South Wales adults, 2001-20, by procedure funding type: a cross-sectional study

OBJECTIVE

To investigate elective rates of spinal fusion, decompression, and disc replacement procedures for people with degenerative conditions, by funding type (public, private, workers' compensation).

DESIGN, SETTING

Cross-sectional study; analysis of hospitals admissions data extracted from the New South Wales Admitted Patient Data Collection.

PARTICIPANTS

All adults who underwent elective spinal surgery (spinal fusion, decompression, disc replacement) in NSW, 1 July 2001 - 30 June 2020.

MAIN OUTCOME MEASURES

Crude and age- and sex-adjusted procedure rates, by procedure, funding type, and year; annual change in rates, 2001-20, expressed as incidence rate ratios (IRRs).

RESULTS

During 2001-20, 155 088 procedures in 129 525 adults were eligible for our analysis: 53 606 fusion, 100 225 decompression, and 1257 disc replacement procedures. The privately funded fusion procedure rate increased from 26.6 to 109.5 per 100 000 insured adults (per year: IRR, 1.06; 95% confidence interval [CI], 1.05-1.07); the workers' compensation procedure rate increased from 6.1 to 15.8 per 100 000 covered adults (IRR, 1.04; 95% CI, 1.01-1.06); the publicly funded procedure rate increased from 5.6 to 12.4 per 100 000 adults (IRR, 1.03; 95% CI, 1.01-1.06), and from 10.5 to 22.1 per 100 000 adults without hospital cover private health insurance (IRR, 1.03; 95% CI, 1.01-1.05). The privately funded decompression procedure rate increased from 93.4 to 153.6 per 100 000 people (IRR, 1.02; 95% CI, 1.01-1.03); the workers' compensation procedure rate declined from 19.7 to 16.7 per 100 000 people (IRR, 0.98; 95% CI, 0.96-0.99), and the publicly funded procedure rate did not change significantly. The privately funded disc replacement procedure rate increased from 6.2 per million in 2010-11 to 38.4 per million people in 2019-20, but did not significantly change for the other two funding groups. The age- and sex-adjusted rates for privately and publicly funded fusion and decompression procedures were similar to the crude rates.

CONCLUSIONS

Privately funded spinal surgery rates continue to be larger than for publicly funded procedures, and they have also increased more rapidly. These differences may indicate that some privately funded procedures are unnecessary, or that the number of publicly funded procedures does not reflect clinical need.

Role of Single-Photon Emission Computed Tomography Imaging in the Diagnosis and Treatment of Chronic Neck or Back Pain Caused by Spinal Degeneration: A Systematic Review

BACKGROUND

Chronic neck or back pain is a common clinical problem. The most likely cause is degenerative change, whereas other causes are relatively rare. There is increasing evidence on using hybrid single-photon emission computed tomography (SPECT) to identify the pain generator in spine degeneration. This systematic review explores the diagnostic and therapeutic evidence on chronic neck or back pain examined by SPECT.

METHODS

This review is reported in accordance with the PRISMA guidelines. In October 2022, we searched the following sources: MEDLINE, Embase, CINAHL, SCOPUS, and 3 other sources. Titles and abstracts were screened and classified into diagnostic studies, facet block studies, and surgical studies. We synthesized the results narratively.

RESULTS

The search yielded 2347 records. We identified 10 diagnostic studies comparing SPECT or SPECT/computed tomography (CT) with magnetic resonance imaging, CT, scintigraphy, or clinical examination. Furthermore, we found 8 studies comparing the effect of facet block intervention in SPECT-positive and SPECT-negative patients with cervicogenic headache, neck pain, and lower back pain. Five surgical studies describing the effect of fusion for facet arthropathy in the craniocervical junction, subaxial cervical spine, or the lumbar spine were identified.

CONCLUSIONS

According to the available literature, a positive finding on SPECT in facet arthropathy is associated with a significantly higher facet blockade effect. Surgical treatment of positive findings has a good effect, but this has not been confirmed by controlled studies. SPECT/CT might therefore be a useful method in the evaluation of patients with neck or back pain, especially in cases of unclear findings or multiple degenerative changes.