PDF(Pubmed)
Abstract：
Pain generator-based lumbar spinal decompression surgery is the backbone of modern spine care. In contrast to traditional image-based medical necessity criteria for spinal surgery, assessing the severity of neural element encroachment, instability, and deformity, staged management of common painful degenerative lumbar spine conditions is likely to be more durable and cost-effective. Targeting validated pain generators can be accomplished with simplified decompression procedures associated with lower perioperative complications and long-term revision rates. In this perspective article, the authors summarize the current concepts of successful management of spinal stenosis patients with modern transforaminal endoscopic and translaminar minimally invasive spinal surgery techniques. They represent the consensus statements of 14 international surgeon societies, who have worked in collaborative teams in an open peer-review model based on a systematic review of the existing literature and grading the strength of its clinical evidence. The authors found that personalized clinical care protocols for lumbar spinal stenosis rooted in validated pain generators can successfully treat most patients with sciatica-type back and leg pain including those who fail to meet traditional image-based medical necessity criteria for surgery since nearly half of the surgically treated pain generators are not shown on the preoperative MRI scan. Common pain generators in the lumbar spine include (a) an inflamed disc, (b) an inflamed nerve, (c) a hypervascular scar, (d) a hypertrophied superior articular process (SAP) and ligamentum flavum, (e) a tender capsule, (f) an impacting facet margin, (g) a superior foraminal facet osteophyte and cyst, (h) a superior foraminal ligament impingement, (i) a hidden shoulder osteophyte. The position of the key opinion authors of the perspective article is that further clinical research will continue to validate pain generator-based treatment protocols for lumbar spinal stenosis. The endoscopic technology platform enables spine surgeons to directly visualize pain generators, forming the basis for more simplified targeted surgical pain management therapies. Limitations of this care model are dictated by appropriate patient selection and mastering the learning curve of modern MIS procedures. Decompensated deformity and instability will likely continue to be treated with open corrective surgery. Vertically integrated outpatient spine care programs are the most suitable setting for executing such pain generator-focused programs.
摘要：
基于疼痛发生器的腰椎减压手术是现代脊柱护理的支柱。与传统的基于图像的脊柱手术医疗必要性标准相比，评估神经细胞侵蚀的严重程度，不稳定性,和畸形，对常见的退行性腰椎疼痛疾病进行分阶段治疗可能更持久且更具成本效益。目标验证的疼痛发生器可以通过简化的减压程序来完成，降低围手术期并发症和长期翻修率。在这篇透视文章中，作者总结了现代经椎间孔镜和经椎板微创脊柱手术技术成功治疗椎管狭窄患者的当前概念。它们代表了14个国际外科医生协会的共识声明，在对现有文献进行系统回顾并对其临床证据的强度进行分级的基础上，他们在开放同行评审模型中合作过。作者发现，根植于经过验证的疼痛发生器的腰椎管狭窄症的个性化临床护理方案可以成功治疗大多数坐骨神经痛类型的背部和腿部疼痛患者，包括那些未能满足传统的基于图像的手术医疗必要性标准的患者，因为近一半的手术治疗疼痛发生器没有显示在术前MRI扫描中。腰椎中常见的疼痛发生器包括（a）发炎的椎间盘，(b)神经发炎，(c)血管过多的疤痕，（d）肥大的上关节突（SAP）和黄韧带，(e)招标胶囊。(f)影响面余量，(g)上椎孔小关节骨赘和囊肿，(h)上椎间孔韧带撞击，(i)隐藏的肩部骨赘。观点文章的主要观点作者的立场是，进一步的临床研究将继续验证基于疼痛发生器的腰椎管狭窄症治疗方案。内窥镜技术平台使脊柱外科医生能够直接可视化疼痛发生器，形成更简化的针对性手术疼痛管理疗法的基础。这种护理模式的局限性取决于适当的患者选择和掌握现代MIS程序的学习曲线。代偿失调的畸形和不稳定可能会继续通过开放矫正手术进行治疗。垂直整合的门诊脊柱护理计划是用于执行此类疼痛发生器聚焦计划的最合适的设置。
