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The existence and importance of an accelerated adjacent segment disc degeneration (ASD) after lumbar fusion have previously not been demonstrated by RCTs. The objectives of this study were, to determine whether lumbar fusion in the long term accelerates degenerative changes in the adjacent disc and whether this affects the outcome, by using a prospective randomised design. A total of 111 patients, aged 18–55, with isthmic spondylolisthesis were randomised to exercise (EX, n  = 34) or posterolateral fusion (PLF, n  = 77), with ( n  = 37) or without pedicle screw instrumentation ( n  = 40). The minimum 10 years FU rate was 72%, with a mean FU time of 12.6 years (range 10–17 years). Three radiographic methods of ASD quantification were used, i.e. two digital radiographic measurement methods and the semi quantitative UCLA grading scale. One digital measurement method showed a mean disc height reduction by 2% in the EX group and by 15% in the PLF group ( p  = 0.0016), and the other showed 0.5 mm more disc height reduction in the PLF compared to the Ex group (ns). The UCLA grading scale showed normal discs in 100% of patients in the EX group, compared to 62% in the PLF group ( p  = 0.026). There were no significant differences between instrumented and non-instrumented patients. In patients with laminectomy we found a significantly higher incidence of ASD compared to non laminectomised patients (22/47 vs. 2/16 respectively, p  = 0.015). In the longitudinal analysis, the posterior and anterior disc heights were significantly reduced in the PLF group, whereas in the EX group only the posterior disc height was significantly reduced. Except for global outcome, which was significantly better for patients without ASD, the clinical outcome was not statistically different in patients with and without ASD. In conclusion, the long-term RCT shows that fusion accelerates degenerative changes at the adjacent level compared with natural history. The study suggests that not only fusion, but also laminectomy may be of pathogenetic importance. The clinical importance of ASD seems limited, with only the more severe forms affecting the outcome.

Background Cage subsidence (CS) was previously reported as one of the most common complications following oblique lumbar interbody fusion (OLIF). We aimed to assess the impacts of CS on surgical results following OLIF combined with anterolateral fixation, and determine its radiological characteristics as well as related risk factors. Methods Two hundred and forty-two patients who underwent OLIF at L4-5 and with a minimum 12 months follow-up were reviewed. Patients were divided into three groups according to the extent of disk height (DH) decrease during follow-up: no CS (DH decrease ≤ 2 mm), mild CS (2 mm < DH decrease ≤ 4 mm) and severe CS (DH decrease > 4 mm). The clinical and radiological results were compared between groups to evaluate radiological features, clinical effects and risk factors of CS. Results CS was identified in 79 (32.6%) patients, including 48 (19.8%) with mild CS and 31 (11.8%) with severe CS. CS was mainly identified within 1 month postoperatively, it did not progress after 3 months postoperatively, and more noted in the caudal endplate (44, 55.7%). In terms of clinical results, patients in the mild CS group were significantly worse than those in the no CS group, and patients in the severe CS group were significantly worse than those in the mild CS group. There was no significant difference in fusion rate between no CS (92.6%, 151/163) and mild CS (83.3%, 40/48) groups. However, significant lower fusion rate was observed in severe CS group (64.5%, 20/31) compared to no CS group. CS related risk factors included osteoporosis (OR = 5.976), DH overdistraction (OR = 1.175), flat disk space (OR = 3.309) and endplate injury (OR = 6.135). Conclusion CS following OLIF was an early postoperative complication. Higher magnitudes of CS were associated with worse clinical improvements and lower intervertebral fusion. Osteoporosis and endplate injury were significant risk factors for CS. Additionally, flat disk space and DH over-distraction were also correlated with an increased probability of CS.

BACKGROUND:Sacroiliac joint (SIJ) dysfunction is a prevalent cause of chronic, unremitting lower back pain. OBJECTIVE:To concurrently compare outcomes after surgical and nonsurgical treatment for chronic SIJ dysfunction. METHODS:A total of 148 subjects with SIJ dysfunction were randomly assigned to minimally invasive SIJ fusion with triangular titanium implants (n = 102) or nonsurgical management (n = 46). Pain, disability, and quality-of-life scores were collected at baseline and at 1, 3, 6, and 12 months. Success rates were compared using Bayesian methods. Crossover from nonsurgical to surgical care was allowed after the 6-month study visit was complete. RESULTS:Six-month success rates were higher in the surgical group (81.4% vs 26.1%; posterior probability of superiority > 0.9999). Clinically important (≥ 15 point) Oswestry Disability Index improvement at 6 months occurred in 73.3% of the SIJ fusion group vs 13.6% of the nonsurgical management group (P < .001). At 12 months, improvements in SIJ pain and Oswestry Disability Index were sustained in the surgical group. Subjects who crossed over had improvements in pain, disability, and quality of life similar to those in the original surgical group. Adverse events were slightly more common in the surgical group (1.3 vs 1.1 events per subject; P = .31). CONCLUSION:This Level 1 study showed that minimally invasive SIJ fusion using triangular titanium implants was more effective than nonsurgical management at 1 year in relieving pain, improving function, and improving quality of life in patients with SIJ dysfunction caused by degenerative sacroiliitis or SIJ disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. ABBREVIATIONS:EQ-5D, EuroQoL-5DINSITE, Investigation of Sacroiliac Fusion TreatmentMCS, mental component summaryNSM, nonsurgical managementODI, Oswestry Disability IndexPCS, physical component summaryRFA, radiofrequency ablationSF-36, Short Form-36SIJ, sacroiliac jointTTO, time trade-offVAS, visual analog scale

We set out to determine whether a minimally invasive approach for one-level instrumented posterior lumbar interbody fusion reduced undesirable changes in the multifidus muscle, compared to a conventional open approach. We also investigated associations between muscle injury during surgery (creatinine kinase levels), clinical outcome and changes in the multifidus at follow-up. We studied 59 patients treated by one team of surgeons at a single institution (minimally invasive approach in 28 and conventional open approach in 31, voluntarily chosen by patients). More than 1 year postoperatively, all the patients were followed up with the visual analogue scale (VAS) and Oswestry disability index (ODI), and 16 patients from each group were evaluated using MRI. This enabled the cross-sectional area (CSA) of lean multifidus muscle, and the T2 signal intensity ratio of multifidus to psoas muscle, to be compared at the operative and adjacent levels. The minimally invasive group had less postoperative back pain ( P  < 0.001) and lower postoperative ODI scores ( P  = 0.001). Multifidus atrophy was less in the minimally invasive group ( P  < 0.001), with mean reductions in CSA of 12.2% at the operative and 8.5% at the adjacent levels, compared to 36.8% and 29.3% in the conventional open group. The increase in the multifidus:psoas T2 signal intensity ratio was similarly less marked in the minimally invasive group where values increased by 10.6% at the operative and 8.3% at the adjacent levels, compared to 34.4 and 22.7% in the conventional open group ( P  < 0.001). These changes in multifidus CSA and T2 signal intensity ratio were significantly correlated with postoperative creatinine kinase levels, VAS scores and ODI scores ( P  < 0.01). The minimally invasive approach caused less change in multifidus, less postoperative back pain and functional disability than conventional open approach. Muscle damage during surgery was significantly correlated with long-term multifidus muscle atrophy and fatty infiltration. Furthermore these degenerative changes of multifidus were also significantly correlated with long-term clinical outcome.

Purpose Tranexamic acid is a proven drug used for reduction of intraoperative blood loss in spinal surgery. However, optimal dosing considering risk/benefits is not well established owing to the heterogeneity in patient selection and surgical procedures of previous studies. This study aimed to evaluate the effectiveness and safety of various tranexamic acid regimens in reducing perioperative blood loss in single-level posterior lumbar interbody fusion (PLIF). Methods Patients were randomly grouped into three different interventions: low-dose tranexamic acid (LD), high-dose tranexamic acid (HD), and placebo-controlled (PC) groups. The HD and LD groups received 10 and 5 mg/kg of bolus loading dose and 2 and 1 mg/kg of continuous infusion until 5 h after surgery, respectively. Data on patient demographics and preoperative and 24-h postoperative laboratory values were collected. Outcome parameters include intraoperative blood loss, 24-h postoperative blood loss, and blood loss during removal of the last drain. Results Seventy-two patients (mean age 63.3 ± 7.6 years) showed similar baseline characteristics. Intraoperatively, blood loss was reduced by the administration of tranexamic acid ( P  = 0.04), contributed predominantly by a difference between the LD and HD groups (123 mL; P  < 0.01). The 24-h postoperative blood loss was reduced ( P  < 0.01), contributed predominantly by a difference between the PC and LD groups (144 mL; P  = 0.02). During the removal of the last drain, statistical difference was found between the PC and HD groups (125 mL; P  = 0.00). No complications or side effects from tranexamic acid use were noted. Conclusion Tranexamic acid administration for single-level PLIF was effective and safe in reducing perioperative blood loss in a dose-dependent manner. An HD regimen comprising 10 mg/kg of bolus loading dose and 2 mg/kg/h of continuous infusion is recommended. Level of evidence Level 1 study according to Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence.

Background The rate and prevalence of lumbar fusion surgeries are rapidly increasing, and these procedures effectively treat spinal disorders. Biological, psychological, and social factors play important roles in postoperative rehabilitation. Robotic-assisted surgeries reduce postoperative morbidities, and postoperative outcomes can be improved by interventions targeting biopsychosocial factors along with rehabilitation. Hence, this study aimed to determine the effect of biopsychosocial model of rehabilitation on pain in patients after robotic-assisted lumbar fusion surgery. Methods An assessor-blinded randomized controlled trial will recruit 136 participants, and randomly allocate the participants into two groups. The intervention group will follow the biopsychosocial rehabilitation model, whereas the control group will be subjected to a routine standard protocol. Assessments will be done at baseline, 2, 4, and 12 weeks post-surgery. The normality of the data will be evaluated using the Shapiro‒Wilk test and analysis of variance with repeated measures or General linear models for intergroup differences. This protocol follows all required ethical guidelines. Discussion This study will address the importance of the biological, psychological and sociological factors of rehabilitation. Analysis of the study results will provide insights into the importance of the biopsychosocial rehabilitation model of rehabilitation in patients after lumbar fusion. Trial registration CTRI, CTRI/2024/12/077598. Registered on 03 December 2024.

Purpose Spinal surgery is associated with severe diffuse pain in the postoperative period. Effective pain management plays an essential role in reducing morbidity and mortality. This study is designed to compare the ultrasound-guided erector spinae plane (ESP) block and surgical infiltrative ESP block for postoperative analgesia management after lumbar spinal fusion surgery. Methods The patients who underwent two or three levels of posterior lumbar spinal fusion surgery were randomly allocated into one of three groups with 30 patients each (Group SE = Surgical ESP block; Group UE = ultrasound-guided ESP block; Group C = Controls). The primary aim was to compare postoperative opioid consumption, and the secondary aim was to evaluate postoperative dynamic and static pain scores and the incidence of opioid-related adverse effects. Results There was a significant difference in terms of opioid consumption, rescue analgesia on demand, and both static and dynamic pain scores between groups at all time periods ( p  < 0.05). Group SE and Group UE had lower pain scores and consumed fewer opioids than the controls ( p  < 0.05). However, the Group UE had lower pain scores and opioid consumption than the Group SE. The sedation level of patients was significantly higher in the control group than in the other two groups. Also, nausea was more common in controls than in the other groups. Conclusion While both surgical and ultrasound-guided ESP blocks reduced opioid consumption compared to the controls, the patients who received ultrasound-guided ESP blocks experienced better postsurgical pain relief than those in the other groups (surgical ESP and controls).

Abstract BACKGROUND In minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), cage type and position play important roles in fusion achievement and sagittal alignment correction. However, no prospective randomized comparison of the results using different types of cage has been reported to date. OBJECTIVE To compare the radiological and clinical outcomes of unilateral MIS-TLIF using 2 types of cage. METHODS All candidates for single-level MIS-TLIF were randomized into banana-shaped cage and straight-cage groups. Plain radiographs and computed tomography scans were used for assessment of cage positions, fusion status, disc height, segmental lordotic angle, cage subsidence, and pelvic parameters. Clinical outcome was assessed using visual analog scale and Oswestry Disability Index scores. RESULTS Forty-four and 40 consecutive patients were operated on using banana-shaped and straight cages, respectively. Cage position was more anterior and lateral in the straight-cage group and more medial and posterior in the banana-shaped cage group. Solid fusion was achieved in 95.2% and 96.6% of the 2 groups, respectively, at 12 mo. The change in disc height and segmental lordotic angle postoperatively was significantly greater in the banana-shaped cage group. The incidence of subsidence during follow-up was significantly higher in the banana-shaped cage group (P < .04). Clinically, the visual analog scale and Oswestry Disability Index scores decreased significantly after surgery in both groups, with no significant difference between the groups. CONCLUSION Our preliminary outcomes suggest that the subsidence rate may be higher using banana-shaped cages in MIS-TLIF, possibly due to their more medial final position.

Purpose To identify the effects of corrective long spinal fusion to the ilium on physical function in patients with adult spinal deformity (ASD). Methods Thirty patients who underwent corrective long spinal fusion to the ilium were prospectively analysed. Patients were divided into the ++ group [sagittal vertical axis (SVA) ≥ 95 mm and pelvic tilt (PT) ≥ 30°, 14 patients] and 0+ group (SVA <95 mm or PT <30°, 16 patients). Subjects’ low back pain [visual analogue scale (VAS) (pain with motion)], muscle strength (knee extensors and hip flexors), balance [timed up and go (TUG)], gait performance [10-metre walking test (10MWT, maximum speed), and 6-minute walk test (6MWT)] were assessed before surgery, at discharge, and 6 and 12 months after the surgery. Results All study patients had a significant improvement in the VAS score between baseline and at discharge, 6 months postoperatively, and 12 months postoperatively. The values of the TUG and 6MWT significantly improved 12 months postoperatively. The values of the TUG, 10MWT, and 6MWT improved significantly more in the ++ group than in the 0+ group at 12 months. Conclusion Corrective long spinal fusion contributed to improving back pain at discharge and gait ability at 12 months in patients with ASD.

Purpose To evaluate the effectiveness of an evidence-based pre-, peri- and postoperative rehabilitation pathway (i.e. the REACT rehabilitation pathway) on disability in patients undergoing lumbar fusion surgery (LFS), compared to usual care. Methods A prospective, nonrandomized controlled trial included 72 patients scheduled for one- or two-level LFS for degenerative conditions or adult isthmic spondylolisthesis. Participants were allocated to usual care (N = 36) or the REACT rehabilitation pathway (N = 36). The REACT rehabilitation pathway includes prehabilitation, early mobilization and avoidance of unsubstantiated postoperative restrictions, early postoperative physiotherapy, patient empowerment, case manager guidance, and support towards an early return to activity. The primary outcome was disability; key secondary outcomes were back and leg pain intensity, and return-to-work rate. Additional secondary outcomes included fear of movement, pain catastrophizing, negative emotional states, sit-to-stand performance, analgesic use, length of stay, and adverse events. Data were collected preoperatively and at five time points up to one year postoperatively. Results Participants in the REACT group demonstrated significantly greater improvements in disability ( p  = 0.003), back pain intensity ( p  = 0.007), and return-to-work rates (88% vs 56%, p  = 0.34) compared to the control group. The REACT group also showed greater improvements in fear of movement ( p  = 0.038), pain catastrophizing ( p  < 0.001), combined negative emotional states ( p  = 0.007), sit-to-stand performance ( p  = 0.021), and reduced analgesic use ( p  = 0.001). No significant differences were observed in leg pain intensity ( p  = 0.042), length of hospital stay ( p  = 0.095) or adverse events ( p  = 1.00). Conclusion The REACT rehabilitation pathway significantly reduced disability in the first postoperative year after LFS compared to usual care. The most promising result is the significantly higher return-to-work rate in the REACT group.