Postoperative pain is an inevitable consequence of spine surgery, yet there remains no universal consensus on the optimal pain management strategy. The complexity of spine procedures, coupled with patient variability, necessitates a multifaceted approach to pain control. Over time, numerous strategies have emerged, each with varying levels of effectiveness. Pharmacological approaches, including multimodal analgesia, local anesthetic infusions, and gabapentinoids, provide relief for both acute and chronic pain. Additionally, perioperative strategies such as enhanced recovery after surgery (ERAS) protocols have demonstrated benefits in optimizing pain control and recovery outcomes. Beyond pharmacological interventions, physical therapy has become a cornerstone of postoperative pain management, aiding in functional recovery and reducing reliance on medications. For patients with refractory or chronic pain, neuromodulatory techniques such as spinal cord stimulation and intrathecal injections offer alternative solutions. Despite the breadth of evidence-based strategies available, limitations persist, including opioid dependence, the complexity of multimodal regimens leading to suboptimal compliance, and cases of refractory pain. These challenges underscore the importance of tailoring pain management approaches to individual patient needs, ensuring a balance between effectiveness and safety. This narrative review of evidence seeks to explore the multifaceted nature of pain management following spine surgery, highlighting the challenges and evolving strategies in optimizing patient outcomes.
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Neurospine 2025;22(2):451-464. Published online June 30, 2025
Objective Preoperative opioid misuse is associated with worse postoperative outcomes. This prospective longitudinal cohort study evaluated the association between preoperative opioid misuse and prolonged pain and opioid use after elective spine surgery; and examined postoperative trajectories of patient-reported outcomes over one year.
Methods Fifty-two patients undergoing elective spine surgery completed presurgical and weekly postoperative longitudinal assessments of pain and opioid use and monthly assessments of depression, anxiety, sleep disturbance, and physical function. Cox regression analyzed the effect of preoperative opioid misuse on time to pain and opioid cessation while linear mixed-effects models examined longitudinal changes in postoperative outcomes.
Results Adjusting for age, sex, operative region, number of spinal levels, and any preoperative opioid use, preoperative opioid misuse (COMM-Positive) was associated with a delayed return to baseline opioid dose (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.14–0.88; p=0.02) and delayed opioid cessation (HR, 0.25; 95% CI, 0.09–0.59; p=0.008). All patients experienced comparable reductions in current and average pain intensity, and pain interference over time. COMM-Positive patients reported a normalization of postoperative anxiety and depression 1 month after surgery with a rebound at 3 months while patients without preoperative opioid misuse remained stable over time.
Conclusion Preoperative opioid misuse is a significant risk factor for delayed opioid cessation even after adjusting for preoperative opioid use, and is associated with a transient normalization of anxiety and depressive symptoms with a rebound 3 months following spine surgery. Targeted screening and risk reduction strategies are needed for patients reporting preoperative opioid misuse before spine surgery.
Objective Extension of the posterior upper-most instrumented vertebra (UIV) into the upper thoracic (UT) spine allows for greater deformity correction and reduced incidence of proximal junction kyphosis (PJK) in adult spinal deformity (ASD) patients. However, it may be associated with chronic postoperative scapular pain (POSP). The goal of this study was to assess the relationship between UT UIV and persistent POSP, describe the pain, and assess its impact on patient disability.
Methods ASD patients who underwent multilevel posterior fusion were retrospectively identified then administered a survey regarding scapular pain and the Oswestry Disability Index (ODI), by telephone. Univariate and multivariate analysis were utilized.
Results A total of 74 ASD patients were included in the study: 37 patients with chronic POSP and 37 without scapular pain. The mean age was 70.5 years, and 63.9% were women. There were no significant differences in clinical characteristics, including mechanical complications (PJK, pseudarthrosis, and rod fracture) or reoperation between groups. Patients with persistent POSP were more likely to have a UT than a lower thoracic UIV (p = 0.018). UT UIV was independently associated with chronic POSP on multivariate analysis (p = 0.022). ODI score was significantly higher in patients with scapular pain (p = 0.001). Chronic POSP (p = 0.001) and prior spine surgery (p = 0.037) were independently associated with ODI on multivariate analysis.
Conclusion A UT UIV is independently associated with increased odds of chronic POSP, and this pain is associated with significant increases in patient disability. It is a significant clinical problem despite solid radiographic fusion and the absence of PJK.
Objective Postoperative dynamic cryo-compression (DC) therapy has been proposed as a method of reducing pain and the inflammatory response in the early postoperative period after orthopedic joint reconstruction surgery. Our aim was to analyze the analgesic efficacy of DC therapy after adult lumbar spinal surgery.
Methods DC was applied for 30 minutes every 6 hours after surgery. Pain was measured by a visual analogue scale (VAS) in the preoperative period, immediately after surgery, and every 6 hours postoperatively for the first 72 hours of the hospital stay. Patients’ pain medication requirements were monitored using the patient-controlled analgesia system and patient charts. Twenty patients who received DC therapy were compared to 20 historical controls who were matched for demographic and surgical variables.
Results In the postanesthesia care unit, the mean VAS back pain score was 5.87 ± 0.9 in the DC group and 6.95±1.0 (p=0.001) in the control group. The corresponding mean VAS scores for the DC vs. control groups were 3.8±1.1 vs. 5.4±0.7 (p < 0.001) at 6 hours postoperatively, and 2.7±0.7 vs. 6.25±0.9 (p<0.001) at discharge, respectively. The cumulative mean analgesic consumption of paracetamol, tenoxicam, and tramadol in the DC group vs. control group was 3,733.3±562.7 mg vs. 4,633.3±693.5 mg (p<0.005), 53.3±19.5 mg vs. 85.3±33.4 mg (p<0.005), and 63.3±83.4 mg vs. 393.3±79.9 mg (p<0.0001), respectively.
Conclusion The results of this study demonstrated a positive association between the use of DC therapy and accelerated improvement in patients during early rehabilitation after adult spine surgery compared to patients who were treated with painkillers only.
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