Objective: To evaluate whether erector spinae plane block (ESPB) combined with local infiltration analgesia (LIA) provides better postoperative analgesia than ESPB alone, LIA alone, or placebo in patients undergoing posterior lumbar interbody fusion (PLIF).Methods: This prospective, double-blind, randomized controlled trial enrolled adults undergoing open PLIF for degenerative lumbar disease. Patients were randomly assigned in a 1:1:1:1 ratio to placebo, LIA, ESPB, or combined ESPB with LIA. Fluoroscopy-guided ESPB or placebo injection was performed before induction of general anesthesia, while LIA or placebo infiltration was given before wound closure. All patients received standardized general anesthesia and postoperative patient-controlled intravenous analgesia. The primary outcomes were postoperative sufentanil consumption and visual analogue scale (VAS) pain scores at rest and during movement at 4, 8, 12, 24, and 48 hours. Analyses were based on the modified intention-to-treat population. Longitudinal VAS trajectories were assessed using linear mixed-effects models, together with multiplicity-adjusted pairwise comparisons and factorial interaction analyses. A right-censoring sensitivity analysis of time to first patient-controlled intravenous analgesia (PCIA) bolus was performed using Kaplan-Meier, log-rank, and adjusted Cox proportional hazards analyses.Results: Of the 188 randomized patients, 182 were included in the modified intention-to-treat analysis. Baseline characteristics were similar across the 4 groups. Body-weight- and operative-time-normalized remifentanil and propofol consumption rates were lower in the ESPB-containing groups, whereas the rocuronium consumption rate did not differ significantly among groups. Linear mixed-effects models showed significant group×time interactions for both resting and movement VAS scores, indicating different postoperative pain trajectories among the groups. The combined ESPB with LIA group showed the most consistent short-term analgesic benefit, with lower pain scores at several early postoperative time points, lower postoperative sufentanil consumption, fewer analgesia pump activations, and a longer time to first PCIA bolus. After multiplicity adjustment, the postoperative rescue analgesia count was also lower in the combined group than in the control group. Factorial analyses identified a greater-than-additive effect only for time to first PCIA bolus, whereas the other analgesic outcomes showed no consistent evidence of statistical synergy. Right-censoring sensitivity analyses supported the longer time to first PCIA bolus in the combined group. Adverse-event rates were similar among the 4 groups, and no significant between-group differences were observed in VAS or Oswestry Disability Index scores at 3 months.Conclusion: Fluoroscopy-guided ESPB combined with LIA improved short-term postoperative analgesia after open PLIF. The combined regimen reduced postoperative opioid requirements and analgesia pump activations and prolonged the time to first PCIA bolus without increasing adverse events. Its benefit is better interpreted as an incremental, layered multimodal analgesic effect rather than a consistently synergistic effect across outcomes. No between-group differences in pain or functional outcomes were observed at 3 months.
Degenerative lumbar spondylolisthesis (DLS) combines neural compression with a variable mechanical phenotype, creating uncertainty over whether decompression alone is sufficient or fusion is required. Over the last few decades, endoscopic spine surgery (ESS) has opened new avenues for ultra-minimally invasive decompression with minimal bony resection, reducing the risk of iatrogenic destabilization. Against this background, the emergence of ESS has added a new dimension to the debate over surgical decision-making in DLS. This debate-style review compares endoscopic decompression versus fusion for DLS across 7 domains: learning curve and training, technical feasibility and surgical nuances, patient selection and indications, clinical and radiological outcomes, complication profile and management, cost-effectiveness and economic analysis, and reoperation/revision rates. The literature supports endoscopic decompression as a tissue-preserving option for carefully selected patients with stable, low-grade DLS and predominant leg symptoms, whereas fusion remains appropriate when objective instability, mechanical pain, or destabilizing decompression makes reconstruction necessary. Clinical outcomes may be similar in selected stable disease phenotypes, but fusion provides more predictable radiographic correction, with the durability of DLS-specific endoscopic outcomes remaining less certain in the longer term. Additionally, endoscopic decompression and fusion have different risk profiles: the former concentrates concerns around technical execution, incomplete decompression, and delayed conversion to revision or later fusion, while the latter introduces potential approach-, implant-, pseudarthrosis-, and adjacent segment-related complications. An international survey of 63 ESS-experienced spine surgeons supported endoscopic decompression for stable single-level disease (60 of 63, 95.2%) and fusion in case of instability (49 of 63, 77.8%), while intermediate scenarios remained divided. Respondents strongly endorsed long-term multicenter randomized comparisons (62 of 63, 98.4%). Because the panel consisted of ESSexperienced surgeons who predominantly favored decompression-only procedures, its results quantify structured expert opinion rather than treatment preferences in the wider spine community. The aggregate evidence therefore supports equipoise rather than a universal winner. The clinically relevant question is which strategy best matches the patient’s symptom generator, mechanical phenotype, operative risk, local resources, and surgeon expertise.
This structured debate integrates a narrative evidence synthesis with an international practice-pattern survey comparing uniportal endoscopic cervical foraminotomy (PECF), unilateral biportal endoscopic cervical foraminotomy (UBE-CF), and microscopic/tubular posterior cervical foraminotomy. The literature search covered January 1990 to July 5, 2026. Comparative evidence was predominantly retrospective, single-center, and heterogeneous. Background and expertise data were available for 75 respondents, including 74 with endoscopic expertise, and 73 completed all 4 clinical scenarios. Uniportal-only respondents predominantly selected PECF, whereas biportal-only respondents favored UBE-CF. Treatment choices differed across the predefined clinical scenarios, with anterior cervical discectomy and fusion (ACDF) selected by 19 of 73 (26.0%), 35 of 73 (47.9%), 19 of 73 (26.0%), and 49 of 73 respondents (67.1%) in cases 1–4, respectively. These scenarios changed several clinical features simultaneously and do not establish the independent influence of any single feature. Available comparative studies have not established durable superiority of one posterior technique over another. ACDF was the most frequently selected single procedure in the scenario combining retrolisthesis, asymptomatic central stenosis, and motor weakness (case 2) and in the revision scenario (case 4). Platform selection should reflect surgeon expertise, anatomy, and available resources. Multicenter randomized or expertise-based comparative trials with standardized outcomes and long-term follow-up are needed.
Objective: This study aimed to identify magnetic resonance (MR) imaging features that can predict relapse after clinical remission in pyogenic spondylodiscitis (PSD) based on simultaneous ¹⁸F-fluorodeoxyglucose positron emission tomography/MR (¹⁸F-FDG PET/MR) imaging data.Methods: This retrospective study included 101 patients (67 men and 34 women) with thoracic, lumbar, and/or sacral PSD who received at least 4 weeks of parenteral antibiotic therapy. All patients underwent ¹⁸F-FDG PET/MR imaging and blood inflammatory markers at the time of clinical remission and antibiotic discontinuation, and were followed for at least 12 months to detect relapse. Clinical variables and ¹⁸F-FDG PET/MR imaging features associated with relapse were analyzed.Results: Relapse occurred in 21 patients (20.8%) and was significantly associated with PSD lesions confined to the thoracic spine (p=0.016), a higher maximum standardized ¹⁸F-fluorodeoxyglucose uptake value (p=0.048), and higher mean signal intensity of edema at the PSD lesion on MR imaging (p=0.005). Regarding Contrast-Edema Mismatch (relative reduction in the edematous area compared with contrast-enhanced area, grades I–III), grade I (<25% difference) was significantly more frequent than grade III (>50% difference) in patients with relapse (p=0.016). Additionally, the mean signal intensity of the contrast area remained similar across grades (p=0.320), whereas the mean signal intensity of edema decreased progressively with increasing grade (p<0.001).Conclusion: Persistent and extensive edematous change on MR imaging was significantly associated with relapse after clinical remission in PSD, and may serve as a potential imaging marker for monitoring treatment response and predicting relapse.
