Degenerative Spine Diseases: Clinical Guidelines

List of Abbreviations

NOS – not otherwise specified

CLBP – chronic low back pain

BP – back pain

VAS – visual analog scale

GC – glucocorticoid

DDT – diadynamic therapy

ZJ – zygapophysial joints

iCT – intraoperative computed tomography

ELF – extremely high frequency therapy

SIJ- sacroiliac joint

CT – computed tomography

PT – physical therapy

LA – local anesthetic

IVD – intervertebral disc

MRI – magnetic resonance imaging

MSCT – multislice computed tomography

NSAIDs – nonsteroidal anti-inflammatory drugs

FMS – functional spinal unit

RCTs – randomized controlled trials

microwave – microwave therapy

Dura mater – dura mater

TPF — transpedicular fixation,

UHF – ultra-high-frequency therapy

LCE – level of confidence of evidence

AAU – average administration unit

GRS – grade of recommendation strength

AFU – average frequency of use

UV – ultraviolet irradiation

COX – cyclooxygenase

NRS – numerical rating scale

TENS – transcutaneous electrical nerve stimulation

II – image intensifier

IF – interbody fusion

DLIF – direct lateral interbody fusion

ODI – Oswestry disability index

PLIF – posterior lumbar interbody fusion

TLIF – transforaminal lumbar interbody fusion

ALIF – anterior lumbar interbody fusion

EQ-5D – European Quality of Life Questionnaire – 5 dimension

C2-HA angle – angle between the vertical line and the line connecting the center of the bicoxofemoral distance and the apex of the C2 vertebra dens

PI – pelvic incidence

PT – pelvic tilt

SS – sacral slope

LL – lumbar lordosis

LLL – low lumbar lordosis (L4-S1)

SVA – sagittal vertebral axis

TK – thoracic kyphosis

Terms and Definitions

Low back pain (LBP) - pain localized between the twelfth pair of ribs and the gluteal folds.

Hypermobility is an increased mobility of a spinal segment, spinal region, the entire spine, or a joint compared to the norm, an adjacent segment, or a symmetrical joint.

Hyperostosis is a pathological increase in bone volume (mainly its thickness) due to the proliferation of bone tissue.

Hypomobility is a reduced mobility of a spinal segment, spinal region, the entire spine, or a joint compared to the norm, an adjacent segment, or a symmetrical joint.

Denervation is the disconnection of any organ or tissue from the nervous system resulting from mechanical (e.g., surgical) disruption of pathway integrity, chemical, or physical exposure.

Discosis (syn. intervertebral disc chondrosis) is a term introduced by neurosurgeons.

Zygapophysial joints are the joints between the articular processes of the vertebrae.

Healthy intervertebral disc is a disc that is structurally and functionally intact regardless of the patient's age.

Sacroiliac joint (articulation) is a plane joint consisting of two surfaces (the surfaces of the sacrum and the ilium) held together by a fibrous capsule and filled with synovial fluid.

Ligamentosis is a degenerative change in the ligamentous apparatus of the spine, consisting of the replacement of the ligament near its attachment to the bone with fibrocartilage, which then becomes calcified and subsequently replaced by bone tissue.

Myelography is an X-ray contrast study of the cerebrospinal fluid pathways of the spinal cord.

Luschka's nerve is the sinuvertebral recurrent nerve, which is a branch of the spinal nerve root; it innervates the vertebra, ligamentous apparatus, and dura mater at the level of the corresponding spinal segment.

Degenerative dystrophic spinal changes constitute a multifactorial, chronic, recurrent degenerative-dystrophic disease originating in the nucleus pulposus of the intervertebral disc, spreading to the annulus fibrosus, and subsequently affecting other elements of the spinal motion segment (SMS), manifesting under certain conditions with polymorphic (reflex, compression, compression-reflex, and reflex-compression) neurological syndromes.

Acute LBP – low back pain lasting no more than 12 weeks.

Spinal motion segment (SMS) is the structural and functional unit of the spine, comprising the intervertebral disc, adjacent vertebral bodies, zygapophysial joints formed by these vertebrae, and ligaments and muscles corresponding to and attaching to these bony structures; its function is to ensure a biomechanically adequate response to external loads.

Protrusion is a type of intervertebral disc herniation in which the base is wider than the portion protruding beyond the vertebral rim.

Segmental instability is a clinically manifest state of increased deformability of the primary and auxiliary load-bearing subsystems of the spinal musculoskeletal system under external forces; a pathological response to applied load characterized by movements within the motion segment exceeding normal limits.

Sequestrated disc herniation is a type of intervertebral disc herniation in which the extruded disc material loses its connection with the parent disc.

Musculoskeletal (nonspecific) LBP – low back pain caused by pathology of the musculoskeletal system elements and not associated with radiculopathy, lumbar stenosis, or specific causes (spinal fracture, infectious, systemic inflammatory, or oncological diseases).

Spondylarthritis is inflammation of the zygapophysial joints. This group sometimes includes inflammation of the costovertebral joints and spinal neoarthroses.

Spondylarthrosis is arthrosis of the joints of the vertebral column – the zygapophysial joints (joints between the articular processes of the vertebrae).

Spondylosis is a form of dystrophic spinal lesion. The disease manifests as bone formation beneath the anterior longitudinal ligament, specific in that the resulting bony bridge arches over the intervertebral disc. Ossification begins at the site where the anterior longitudinal ligament detaches from the vertebral body. The term is well established in radiology and pathomorphology. In literature, it is frequently misused as an umbrella term for all dystrophic spinal lesions. In this meaning, it is also cited in the Encyclopedic Dictionary of Medical Terms, which cannot be considered correct for professional literature.

Spondylolisthesis is a polyetiological pathological process occurring in the spine, characterized by the displacement of one vertebra relative to another in the sagittal or frontal plane, causing a complex of pathophysiological, pathomorphological, biochemical, and biomechanical changes in the spinal motion segment, the spine, and the musculoskeletal system as a whole, which may be asymptomatic or present with pronounced clinical manifestations.

Stable displacement is a displacement of vertebrae relative to each other identified on radiographs, the magnitude of which does not change during spinal movements, as determined by functional radiography.

Aging disc is an intervertebral disc that, regardless of the patient's age, is structurally intact, but its functional capacity is reduced.

Spinal stenosis is a mismatch between the capacity of the osteofibrous spinal canal and its neurovascular contents, resulting in the development of initially transient and subsequently persistent organic compression-ischemic lesions of the nervous system. A reduction in the dimensions of the spinal canal relative to its contents that does not cause compression of vessels and neural structures and does not lead to clinically significant changes in their functions can be termed a narrow canal, but not stenotic.

Tendinosis is a dystrophic change in a muscle tendon manifested by the replacement of tendon tissue at its attachment site to the bone with fibrocartilage, which first calcifies and is subsequently replaced by bone. Radiologically, it manifests as calcification and ossification of the tendon area near the bone surface, which becomes uneven, with bony outgrowths or deposits. Clinically, tendinosis manifests as localized pain and tenderness upon palpation and tension of the corresponding muscles. In the case of a short tendon, a portion of the muscle may be involved in the dystrophic process. In such cases, the term "myotendinosis" becomes appropriate.

Diffuse idiopathic skeletal hyperostosis is widespread bone formation beneath the anterior longitudinal ligament of the spine, occurring in elderly individuals. The thoracic and lumbar regions are primarily affected, and sometimes the cervical region. The thickness of the bridging deposits can reach 1 cm or more. In the early stage, it must be differentiated from spondylosis and ankylosing spondylitis (Bechterew's disease).

Ossifying ligamentosis is an inaccurate term, since the anterior longitudinal ligament itself is not affected by the dystrophic process in this disease. On the contrary, the function of its cambial layer, which possesses periosteal properties, is sharply enhanced.

Chronic LBP – low back pain lasting for more than 3 months.

Extrusion is a type of intervertebral disc herniation in which the size of its base is smaller than the size of the protrusion beyond the vertebral rim.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Degenerative disc disease of the spine (degenerative-dystrophic spinal changes) is a multifactorial, chronic, recurrent disease. Changes primarily appear in the nucleus pulposus of the intervertebral disc, spread to the annulus fibrosus, and then to other elements of the spinal motion segment (SMS), manifesting under certain conditions with polymorphic (reflex, compression, compression-reflex, and reflex-compression) neurological syndromes [1].

Degenerative spinal stenosis is a pathological narrowing of the central spinal canal, lateral recess, or intervertebral foramen due to the intrusion of bony, cartilaginous, or soft-tissue structures, manifesting as clinical symptoms of nerve root and/or spinal cord compression and ischemia.

Degenerative spondylolisthesis is an anterior displacement of the upper vertebra relative to the lower one, resulting from degenerative changes in the SMS elements [1].

Sacroiliac joint dysfunction is a condition characterized by altered mobility in this joint, with its locking or micro-instability, which leads to concurrent inadequate stress loads on the surrounding tissues (capsule, ligaments, muscles, bones).

Sacroiliitis is an inflammatory process in the sacroiliac joint, which can be either an independent disease or a symptom of other infectious or autoimmune conditions.

Spondylarthrosis is a lesion of the zygapophysial joints (Z-joints) that develops in the same sequence of morphological changes as in osteoarthritis of peripheral joints. Spondylarthrosis accompanies advanced age in 85–90% of cases [1].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

To date, there are no exact data on the etiology of degenerative spinal diseases. There are only a number of theories considering various factors as causes of degenerative spinal lesions: involutive, dysontogenetic, mechanical, immune, hormonal, dysmetabolic, vascular, infectious, functional, and hereditary.

The most widespread is the involutive theory, according to which local premature aging of cartilage and bone occurs as a result of prior injuries – mechanical, inflammatory, etc. [2]. According to this theory, the development of involutive degenerative changes in the spine is genetically predetermined, while the onset of degeneration as a disease, with corresponding clinical manifestations, is driven by the influence of various endogenous and exogenous factors.

While the cause of degenerative-dystrophic changes cannot always be established, their pathogenesis has been quite well investigated. However, even in this area of studying degenerative-dystrophic changes, there are debatable points.

Intervertebral disc degeneration develops when matrix protein catabolism begins to prevail over synthesis. A crucial triggering factor for this may be impaired disc nutrition. The intervertebral disc is one of the most avascular tissues in the human body. As the IVD grows, its vascularization decreases, leading to a reduced supply of nutrients to the tissues. This diminishes the disc cells' ability to synthesize new matrix and limits their proliferative potential, resulting in a decreased cell density within the disc with age. Histological studies show that the cause of the onset of involutive and/or degenerative changes in intervertebral discs is impaired nutrition due to the disappearance of blood vessels in the vertebral endplates [1].

At the molecular level, disc degeneration manifests as decreased diffusion of nutrients and catabolic waste products, reduced cell viability, accumulation of cell fragments (due to apoptosis) and degenerated matrix macromolecules, decreased proteoglycan synthesis, and damage to the normal collagen framework [3].

These changes lead to dehydration (due to decreased chondroitin sulfate concentration). Consequently, the nucleus pulposus loses its hydrostatic properties—meaning it loses the ability to distribute vertical loads evenly throughout its volume and no longer protects the annulus fibrosus from uncharacteristic compressive forces. The annulus fibrosus becomes subject to constant mechanical stress, resulting in pathological changes: disorganization of the normal lamellar structure due to damage to the collagen matrix, which leads to fissures and tears in the annulus fibrosus. With the development of such changes, the intervertebral disc becomes vulnerable to the destructive impact of biomechanical factors arising under normal human activity loads and stresses. As a result of decreased pressure within the disc, the tension of the annulus fibrosus fibers decreases, the fixation properties of the disc are impaired, and pathological mobility occurs in the FSU. Thus, the underlying concept of this pathogenesis model for degenerative-dystrophic changes is that pathological mobility is a consequence, rather than the cause, of disc degeneration.

Another factor in the pathogenesis of IVD degenerative changes is the ingrowth of nerves and blood vessels into the annulus fibrosus of the intervertebral disc, which is an important feature of structurally damaged discs [3].

This ingrowth occurs due to the loss of hydrostatic pressure characteristic of the inner regions of intact discs. The reduced proteoglycan content in degenerated discs also facilitates the ingrowth of nerves and capillaries [4].

However, the presence of blood vessels and nerve fibers cannot influence the regenerative capacity of the cell, since the architectonics in which they functioned normally and the ultrastructural interactions have been lost.

Spondyloarthritis is more often secondary to degenerative-dystrophic changes of the intervertebral disc. A decrease in the height of the affected disc and/or pathological mobility of the vertebrae inevitably leads to FSU overload, functional insufficiency, and subsequently dystrophic lesions of the articular processes. Primary spondyloarthritis is much less common. It is usually associated with trauma or significant chronic overload of the spinal joints. As in osteoarthritis of other joints, spondyloarthritis involves subchondral sclerosis, necrosis of articular cartilage, irregularity of articular surfaces, and subsequently marginal bony outgrowths of these processes to increase the bearing surface area for inadequate articular cartilage. Overstretching and dystrophy of the capsular-ligamentous apparatus lead to pathological mobility of the vertebrae. Protective bone spurs frequently form on the articular processes, sharply restricting joint mobility. Pathological signaling from affected joints forms local, referred, and other more complex reflex-pain syndromes, commonly referred to in the literature as facet syndrome.

Bone outgrowths of the articular processes can exert a dynamic and subsequently persistent compressive effect on adjacent neurovascular structures, leading to compression syndromes of spondyloarthritis. These are often mistakenly perceived as clinical manifestations of degenerative-dystrophic changes of the spine, which can result in ineffective surgical treatment if compression by bone outgrowths of the articular processes persists after removal of the compressive factor in the form of a disc herniation. Spondyloarthritis is rarely an isolated process. When presenting with complaints of «back pain», it is typically diagnosed in combination with other pathology.

Etiological factors of SIJ pain include intra-articular and extra-articular factors. Intra-articular factors include: arthritis or sacroiliitis in systemic diseases and infections, as well as SIJ arthrosis. Extra-articular factors include: fractures, ligament injuries, and enthesopathies around the SIJ, pregnancy, and post-stabilization surgery states of the lumbar spine [5].

1.3 Epidemiology of the Disease or Condition

Degenerative conditions of the spine and associated pain and neurological manifestations represent one of the most critical issues in modern medicine. This is due to the consistently high number of working-age patients, often unsatisfactory results of conservative therapy, and frequent relapses of pain syndrome following surgical treatment. Back pain limits daily functioning, reduces patients' quality of life, and alters psychological state and behavior [6]. More than half of patients suffering from degenerative-dystrophic changes of the spine show signs of chronic emotional stress.

The incidence of manifestations of intervertebral disc degenerative-dystrophic changes is growing exponentially due to demographic shifts and the increasing average age of the population. The proportion of degenerative-dystrophic changes of the spine affecting individuals in the most socially active group accounts for 20% to 80% of temporary disability cases [7].

In the overall morbidity structure of the adult population in our country, degenerative-dystrophic changes account for 48–52%, ranking first in terms of days of disability [8].

Temporary disability caused by non-compressive syndromes of degenerative-dystrophic changes accounts for 40% of neurological diseases. In the overall structure of disability caused by musculoskeletal system disorders, degenerative spinal diseases account for 20.4% and rank first (41.1%) among the causes of primary disability [7].

The disability rate for degenerative spinal diseases is 0.4 per 10,000 population. Vertebrogenic pathology is the leading disorder in the morbidity structure of the peripheral nervous system, with degenerative-dystrophic changes of the spine occupying the primary place (77–81%) [9].

Among disabled individuals with peripheral nervous system diseases, vertebrogenic lesions are observed in 80% of cases.

Patients with clinically significant manifestations of degenerative-dystrophic changes of the spine make up 51.2 per 1,000 population. Compression and non-compression forms of degenerative-dystrophic changes begin to be diagnosed from 15–19 years of age (2.6 cases per 1,000 population in this age group), and by age 30, clinical manifestations of degenerative-dystrophic changes are diagnosed in 1.1% of the population, and by age 59, in 82.5% of the population [10].

According to various researchers, despite the broad capabilities of conservative therapy, 5% to 33% of patients require surgical treatment for degenerative-dystrophic changes of the spine [10].

Pronounced facet joint lesions were found by the authors in 80% of individuals aged 20–30 years and up to 100% in older age groups.

Spondyloarthritis is not only associated with advanced age (85–90% of cases) but also manifests in young patients aged 25–30 years. Potential causes for the development of spondyloarthritis include:

• spinal trauma with subluxation in the spinal joints;

• constant increased loads on the spine leading to incorrect load distribution across its segments (sedentary work, professional sports, flat feet, heavy lifting);

• congenital spinal anomalies, vertebral instability, spondylolisthesis, spondylolysis;

• degenerative-dystrophic changes of the spine.

SIJ dysfunction is detected in 15–30% of patients with non-specific low back pain [11].

1.4 Features of Coding the Disease or Condition

M19.8 - Other specified arthrosis

M41.5 – Secondary scoliosis

M42.1 - Spinal osteochondrosis in adults

M42.9 - Spinal osteochondrosis, unspecified

M43.1 - Spondylolisthesis

M46.1 - Sacroiliitis, not elsewhere classified

M47.0 - Spondylosis

M47.1 - Other spondylosis with myelopathy

M47.2 - Other spondylosis with radiculopathy

M48.0 - Spinal stenosis

M50.0 - Cervical disc disorder with myelopathy

M50.1 - Cervical disc disorder with radiculopathy

M50.3 - Other cervical disc degeneration

M50.8 - Other cervical disc disorders

M50.9 - Cervical disc disorder, unspecified

M51.0 - Lumbar and other intervertebral disc disorders with myelopathy

M51.1 - Lumbar and other intervertebral disc disorders with radiculopathy

M51.2 - Other specified intervertebral disc displacement

M51.3 - Other specified intervertebral disc degeneration

M53.0 - Cervicocranial syndrome

M53.1 - Cervicobrachial syndrome

M53.2 - Spinal instability

M54.2 - Cervicalgia

M54.3 - Sciatica

M54.4 - Lumbago with sciatica

M54.5 - Low back pain

M54.6 - Pain in thoracic spine

M54.8 - Other dorsalgia

M54.9 - Dorsalgia, unspecified

M96.4 - Postprocedural lordosis

M96.8 - Other musculoskeletal disorders following medical procedures

M96.9 - Musculoskeletal disorder following medical procedures, unspecified

M99.5 - Intervertebral disc stenosis of neural canal

M99.6 - Osseous and subluxation stenosis of intervertebral foramina

M99.7 - Connective tissue and disc stenosis of intervertebral foramina

S33.6 - Sprain and strain of sacroiliac joint

1.5 Classification of the disease or condition

The clinical and pathogenetic A.I. Osna classification reflects four consecutive stages of degenerative-dystrophic lesions [12]:

• Stage of the intradiscal pathological process ("chondrosis"), which generates pathological impulses from the affected disc. During this period, intradiscal migration of the nucleus pulposus occurs. The nucleus pulposus penetrates through fissures in the annulus fibrosus into its richly innervated outer fibers. As a result, nerve endings are irritated, and pain develops, forming reflex syndromes of degenerative-dystrophic changes.

• Stage of instability or loss of the fixation capacity of the affected disc, dynamic displacement of the overlying vertebra relative to the underlying one (due to fissuring of not only the nucleus pulposus but also elements of the annulus fibrosus). During this period, instability syndrome, reflex syndromes, and even certain compression syndromes may form.

• Stage of intervertebral disc herniation formation due to disruption of the integrity of the annulus fibrosus (protrusion or prolapse), which can compress adjacent neurovascular structures, including the spinal nerve root.

• Stage of intervertebral disc fibrosis and formation of marginal osteophytes of the vertebral bodies, which is predominantly sanogenic because immobility and a compensatory increase in the vertebral bearing area on compromised discs occur. In some cases, these bone outgrowths, like disc herniations, can compress adjacent neurovascular structures.

L. Armstrong's classification (1952) also correlates changes in the spinal motion segment with the clinical manifestations of degenerative-dystrophic changes in the spine [1].

Stage I. Initial dystrophic changes in the nucleus pulposus and the posterior part of the annulus fibrosus, which swells and protrudes toward the spinal canal, irritating the receptors of the posterior longitudinal ligament of the dura mater; back pain appears.

Stage II. The displaced nucleus pulposus lies within the protruded part of the annulus fibrosus, through the defect of which a disc herniation prolapses; clinically, radicular symptoms appear along with, frequently, pronounced antalgic components of the vertebral syndrome.

Stage III. Degeneration of the prolapsed disc progresses, both subligamentously and in the epidural space beyond the perforated posterior longitudinal ligament. Resorption or ossification of disc parts and its fibrosis begin. Bone outgrowths ("osteophytes") may form in the area of the posterior longitudinal ligament rupture. The prolapse of sequestra frequently causes cicatricial-adhesive aseptic epiduritis. Direct pressure on the root decreases, and the disease takes on a chronic course.

Classification of intervertebral disc degeneration by Pfirrmann C.W. et al. (2001) [13]. The stage of intervertebral disc degeneration is evaluated on T2-weighted MRI scans (Table 1)

Table 1. Classification of intervertebral disc degeneration by Pfirrmann et al. (2001).

1.5.1 Classification of intervertebral disc herniations

North American Spine Society Classification (2014) [14]:

• protrusion - displacement of disc tissue beyond the margins of the vertebral body limbus, where the base of the herniated protrusion is larger than the longitudinal dimension of the protrusion;

• extrusion - displacement of disc tissue beyond the margins of the vertebral body limbus, where the base of the herniated protrusion is smaller than the longitudinal dimension of the protrusion;

• sequestration - complete separation of the displaced fragment from the disc.

Additional classification of intervertebral disc herniation is possible to specify its localization, displacement, consistency, etc.

1.5.2 Classifications of spinal stenosis

H. Verbiest classification [15]

I. Etiology: congenital and developmental stenosis

II. a. Pure absolute stenosis (sagittal diameter of the spinal canal is 10 mm or less)

b. Pure relative stenosis (sagittal diameter of the spinal canal 10-12 mm)

c. Mixed stenosis

1) Stenosis produced by the bony walls of the spinal canal:

A. Congenital stenosis

B. Developmental stenosis resulting from congenital growth errors

C. Idiopathic developmental stenosis

D. Acquired stenosis

E. Recurrent stenosis

2) Stenosis produced by non-bony components of the spinal canal walls:

A. Hypertrophy with (or without) calcification of the posterior longitudinal or ligamentum flavum, or both.

B. Massive central disc herniation or massive subligamentous spread of sequestered disc material

Arnoldi classifications of spinal canal stenosis [16]

I. Congenital

a. Idiopathic

b. Achondroplastic

II. Acquired

a. Degenerative stenosis

i. Central spinal canal

ii. Peripheral spinal canal

iii. Degenerative spondylolisthesis.

b. Combined (any combinations of congenital/

acquired stenosis, degenerative stenosis, and disc herniation)

c. Spondylolisthesis with spondylolysis

d. Iatrogenic

i. Post-laminectomy

ii. Post-anterior and posterior fusion

iii. Post-chemonucleolysis of the disc

e. Late post-traumatic spinal changes

f. Other types of stenosis: disease

i. Paget's

ii. Fluorosis.

From a practical standpoint, the anatomical classification of stenosis is convenient, distinguishing the following forms: central stenosis, lateral stenosis, intervertebral canal stenosis (foraminal stenosis), and combined stenosis. Lateral stenoses are described in detail and classified by Lee et al. [17]. The entrance zone to the intervertebral foramen is the lateral recess, and the causes of radicular compression here are hypertrophy of the superior articular process, congenital developmental features of the zygapophyseal joints, and vertebral body margin osteophytes. The middle zone is bounded anteriorly by the posterior surface of the vertebral body; the medial parts of this zone open toward the central canal. The main causes of stenosis in the middle zone are vertebral body osteophytes or osteophytes at the attachment site of the ligamentum flavum, as well as hypertrophy of the ligamentum flavum. In 41.7% of cases, a so-called intraforaminal ligament is present, changes in which can cause nerve root compression. The exit zone of the intervertebral foramen is bounded anteriorly by the underlying intervertebral disc and posteriorly by the outer parts of the zygapophyseal joints. Causes of compression in this zone include hypertrophic changes and subluxation of the zygapophyseal joints, and osteophytes of the superior margin of the intervertebral disc.

MRI-based classification of spinal canal stenosis by C. Schizas (2010) [18] (Fig. 1):

• Class A: CSF is visible within the dural sac, but its distribution is inhomogeneous. Roots are identifiable, epidural fat is present. This group is subdivided into subgroups A1 to A4: A1 – roots lie dorsally and occupy less than half of the dural space; A2 – roots lie dorsally in contact with the dura mater, but in a horseshoe shape; A3 – roots lie dorsally and occupy more than half of the dural sac area; A4 – roots lie centrally and occupy most of the dural sac area.

• Class B: nerve root concentration is determined, no cerebrospinal fluid level, roots are evenly distributed in the slice and distinguishable, epidural fat is present.

• Class C: implies the presence of nerve root concentration, cerebrospinal fluid is not visible, epidural fat is determined.

• Class D: complete canal stenosis, no cerebrospinal fluid level, cerebrospinal fluid is not visible, no epidural fat.

Figure 1. Classification of lumbar spinal stenosis by C. Schizas.

1.5.3 Classification of degenerative spondylolisthesis (Tab. 2)

Table 2. O. Gille classification (2017).

1.5.4 Classification of degenerative scoliosis and sagittal balance disorders

Aebi classification [19]

Type 1: primary degenerative scoliosis ("de novo scoliosis")

Type 2: idiopathic juvenile scoliosis of the thoracic and/or lumbar spine with curve progression during adult life

• without marked secondary degenerative changes

• with marked secondary degenerative changes

Type 3: secondary adult scoliosis

• due to limb length discrepancy, pelvic tilt, lumbosacral anomalies, idiopathic, neuromuscular or congenital scoliosis, trauma, or iatrogenic causes

• due to metabolic bone disorders (osteoporosis)

Classification accounting for curve type and 3 sagittal parameters: PI – pelvic incidence; LL – lumbar lordosis; PT – pelvic tilt; SVA – sagittal vertical axis (Fig. 2).

Figure 2. SRS-Schwab classification [20].

Criteria for adult scoliosis classification according to surgical treatment strategy (Table 3).

Table 3. P. Berjano and C. Lamartina classification (2013) [21].

1.5.5 Classification of spondylarthrosis (Tab. 4)

Table 4. Classification of the stages of articular cartilage degeneration and subchondral sclerosis of the facet joints according to MRI by Grogan, 1997 [12].

1.6 Clinical presentation of the disease or condition

Clinical symptoms and syndromes of degenerative and dystrophic changes of the spine can be divided into reflex and compression types.

A. Compression syndromes of degenerative and dystrophic changes of the lumbar spine:

1) Radicular compression syndrome.

• compression of the upper lumbar roots (L1–L3) is rare.

• L4 root syndrome (L3-L4 disc) – radiation of pain to the anteromedial thigh, leg, and medial malleolus; hypesthesia on the anterior surface of the thigh; weakness of the quadriceps muscle; diminished or absent knee jerk;

• L5 root syndrome (L4-L5 disc) – radiation of pain from the upper gluteal region to the lateral thigh and leg, sometimes extending to the dorsum of the foot and the 1st–3rd toes; hypesthesia in the same area; weakness of the peroneal muscle group; possible hypotrophy; weakness of the extensor hallucis longus;

• S1 root syndrome (L5-S1 disc) – radiation of pain from the middle gluteal region to the posterolateral or posterior thigh, leg, and heel, extending to the lateral edge of the foot and the 4th–5th toes; hypesthesia in the posterolateral leg and lateral foot; hypotrophy of the gluteus maximus and gastrocnemius muscles; weakness of the gastrocnemius muscle; diminished or absent Achilles and plantar reflexes.

2) Neurogenic intermittent claudication (Déjerine syndrome). Pathogenetic mechanism: mechanical compression and ischemia of neural structures. Ischemia increases in the upright position (standing while walking). During walking, segmental rotation leads to further narrowing of the spinal canal and impaired blood supply to the spinal cord and its elements. This syndrome features a clinical triad: pain, sensory impairment, and motor deficit. A distinctive feature is that these symptoms may be absent at rest in the supine position, but appear upon verticalization and walking.

3) Polyradicular compression syndrome. Manifests with the clinical picture of compression of two or more roots of the cauda equina.

4) Caudad-medullary syndrome. This syndrome occurs due to compression of both the cauda equina roots and the radiculomedullary artery (Déproge-Gotteron), leading to ischemia of the conus medullaris and epiconus. The clinical picture includes lower flaccid paraparesis, peripheral-type pelvic organ dysfunction, and segmental/radicular sensory disturbances in the anogenital region and lower extremities.

B. Compression syndromes of cervical osteochondrosis:

• Radicular syndrome

o C₄ root compression syndrome – manifested by pain in the shoulder girdle, may be accompanied by amyotrophy of the trapezius, supraspinatus, and even pectoralis major muscle.

o C₅ root compression syndrome – projected pain and sensory disturbances are localized in the area of the deltoid muscle, may be accompanied by its weakness and hypotrophy, and a diminished scapular reflex.

o C₆ root compression syndrome – projected pain and sensory disturbances are localized as a strip along the lateral border of the arm down to the thumb of the hand. The strength of forearm flexor muscles decreases, and the biceps reflex is impaired.

o C₇ root compression syndrome – projected pain and sensory disturbances are localized as a strip on the dorsal aspect of the arm, especially in the middle three fingers. The triceps reflex is usually diminished or absent. Autonomic-trophic disorders in the hand may occur.

o C₈ root compression syndrome – the projection of pain and sensory disturbances corresponds to the ulnar border of the arm, including the fourth and fifth fingers. The brachioradialis reflex may be diminished.

• Spinal cord compression syndrome (myelopathy). This syndrome manifests as motor and sensory segmental disorders at the level of compression, long-tract signs below the level of spinal cord compression, central-type pelvic organ dysfunction, and pathological reflexes.

C. Reflex (non-compression) syndromes of lumbar spine osteochondrosis:

1) local pain syndromes (lumbalgia, lumbago);

2) reflex referred syndromes (lumboischialgia, pseudoabdominal pain, pseudogenital pain, etc.);

3) reflex myodystonic syndromes, including reflex-compression or tunnel syndromes:

a) minimus gluteus muscle syndrome;

b) medius gluteus muscle syndrome;

c) piriformis syndrome;

d) "symphysis-sternal syndrome", "symphysis syndrome", abdominalgia syndrome, pubalgia;

e) vertebrogenic iliopsoas syndrome;

f) muscle-tonic disorders in hip abductors, "gluteal-tract syndrome";

g) adductor syndrome;

h) tonic disorders in the hamstring muscles of the thigh;

i) tonic disorders in the tibialis anterior muscle;

k) cramps;

4) reflex myosclerotomic (dystrophic) syndromes:

a) trochanteritis;

b) knee epicondylitis;

c) ankle and foot periarthrosis, metatarsalgia;

d) secondary compression syndromes of the leg nerves associated with connective tissue dystrophy (entrapment tunnel syndromes of peripheral nerves);

5) reflex angiopathic syndromes:

a) leg vascular dystonia with predominant vasospasm or vasodilation;

c) local extravertebral compression and reflex vasodistonia;

d) subpiriformis intermittent claudication syndrome;

e) restless legs syndrome;

f) general vertebrogenic and reflex vasodistonia;

g) obliterating vascular disease of the legs syndrome;

6) discogenic pathobiomechanical syndromes of the spine or other joints: functional blocks, regional postural muscle imbalance, non-optimal movement pattern [1].

C) Reflex (non-compression) syndromes of cervical spine osteochondrosis:

1. Local vertebral syndromes;

2. Referred pain syndromes;

3. Reflex myodystonic syndromes;

• Inferior oblique muscle of the head syndrome

• Anterior scalene syndrome

• Levator scapulae muscle syndrome (scapulocostal syndrome);

• Pectoralis minor syndrome;

• Tunnel syndromes of the nerves of the neck and arm

4. Reflex dystrophic syndromes;

• Scapulohumeral periarthrosis;

• Shoulder-hand syndrome;

• Epicondylosis;

• Myofascial syndromes;

• Anterior chest wall syndrome;

• Multiple neuroosteofibrosis syndrome

5. Reflex angiopathic (neurovascular) syndromes;

• Vertebral artery dystonic syndrome;

• Angiopathic cardialgic syndrome;

• Angiopathic spinal syndrome;

• Angiopathic brachial syndromes.

6. Discogenic pathobiomechanical disorders

Pain associated with sacroiliac joint pathology may be localized in the lower back, sacrum, pelvis, and gluteal region. Typically, pain is localized no higher than the waist level, below the level of the L5 vertebra. The pain pattern may radiate down the posterior aspect of the leg to the knee level. Most commonly, pain syndrome in SIJ pathology is unilateral [22]. An important sign indicating the etiological role of the SIJ in lumbosacral spine pain is a positive Fortin finger test.

To assess the intensity of the pain syndrome, a visual analogue scale (VAS) or numerical rating scale (NRS) is used (Appendix G1) [23]. Assessment of the quality of life in patients with lumbar osteochondrosis is carried out using the Oswestry Disability Index (ODI) (Appendix G2) and the European Quality of Life Questionnaire – 5 dimensions (EQ-5D) (Appendix G3) [23, 24]. Assessment of the quality of life in patients with cervical osteochondrosis is carried out using the Neck Disability Index (NDI) (Appendix G5) [25]. Assessment of the neurological status of patients with cervical myelopathy is performed using the Frankel neurological status scale (Appendix G4) [26, 27]. Clinical scales and questionnaires are very widely used to evaluate treatment efficacy. However, statistically significant differences do not always mean an improvement in outcomes from the patient's perspective. For this purpose, the minimum clinically important difference (MCID) parameter is used [28]. The MCID for each scale has different values across various observation periods, types of pathology, and types of surgical care.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the disease or condition: the diagnosis is established based on complaints, clinical examination, and magnetic resonance imaging of the spine. If necessary, the diagnosis can be refined based on laboratory test data, spine and joint radiography data, special studies and projections, vertical full-length spine radiography with functional tests, and computed tomography of the spine.

2.1 Complaints and Anamnesis

Described in the "Clinical presentation" section (see section 1.6)

2.2 Physical Examination

Comments: A pathological posture with antalgic scoliosis may be detected, as well as changes in physiological thoracic kyphosis and lumbar lordosis. It is necessary to determine whether these posture changes arose at the onset of the pain attack or existed previously. Placing the palms of both hands on the iliac crests on both sides and positioning the thumbs at the level of the palms, palpation of the paraspinal muscles is performed, noting their tenderness. Having fixed the pelvis with your hands, or if possible, having the patient sit on a chair, they should be asked to bend forward, backward, and sideways as much as possible, and perform rotational movements of the torso, observing the nature of the spinal column movements and inquiring about the degree of movement pain and where exactly the pain is felt. Normally, all these movements should be smooth and symmetrical in amplitude. An axial load test on the spine is performed (pressure on the head, shoulders), which may be painful. Active flexion of one and then the other leg in the hip joint by the patient themselves in the supine position usually causes pain in the primary pathology zone (gluteal, sacral) due to the inevitable contraction of muscles in this area.

In the supine position, it is necessary to determine tension signs:

- Lasègue's sign – the patient lies supine with legs extended at the hip and knee joints. Next, the left and right lower limbs are alternately flexed at the hip joint with the knee joint extended until pain appears or intensifies along the dermatome of the L5 or S1 root. The sign is considered positive if pain occurs or increases before reaching 45 degrees relative to the horizontal.

- Wasserman's sign – occurrence or intensification of pain in the L3, L4 root dermatome zones during extension of the leg at the hip joint in a patient lying prone.

Comments: For subsequent diagnosis of SIJ pathology, provocative tests, additional diagnostic methods (pelvic radiography, joint magnetic resonance imaging, joint computed tomography, diagnostic local anesthetic blocks under fluoroscopic guidance [29] can be used.

Provocative neuroorthopedic tests:

1. compression test;

2. distraction test;

3. thigh thrust test;

4. FABER (Patrick's) test;

5. sacral thrust test;

6. Yeoman test;

7. Gaenslen test.

In 2 systematic reviews (Hancock et al.) [30], (Szadek et al.) [31], as well as in 1 blinded prospective study (Laslett et al.) [32], the diagnostic value of tests for detecting sacroiliac joint pathology as a cause of lower back pain was evaluated. The authors of the studies established that a combination of 3 provocative tests makes it possible to diagnose sacroiliac joint pathology as the primary source of symptoms in patients with pain below the fifth lumbar vertebra. If all six SIJ provocation tests are negative, SIJ pathology can be excluded.

Comment: Risk factors for cardiovascular disease development include: arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol in men <1.0 mmol/L, in women <1.2 mmol/L, and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of cardiovascular disease at a young age (<55 years for men and <65 years for women) [33]. Established cardiovascular disease is understood to mean: coronary heart disease, cerebrovascular disease, peripheral atherosclerosis, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies [34].

Comments: When surgical treatment is performed for emergency (<6 hours) and urgent (6–24 hours) indications, preoperative risk assessment is not performed.

Minor orthopedic procedures are associated with a low risk of cardiovascular complications (the 30-day risk of myocardial infarction or death from cardiovascular causes after surgery is less than 1%). Major orthopedic procedures are associated with an intermediate (moderate) risk of cardiovascular complications (the 30-day risk of myocardial infarction or death from cardiovascular causes after surgery is 1–5%) [35].

2.3 Laboratory Diagnostics

2.4 Instrumental Diagnostics

Comments: Magnetic resonance imaging (MRI) of the spine visualizes concomitant soft tissue changes, makes it possible to detect the finest changes in cartilage, bones, ligaments, and vessels, allows with high accuracy to determine the localization of hernia protrusion along the length and cross-section of the spinal canal, the degree of intervertebral disc degeneration and cerebrospinal fluid circulation disorders during dural sac compression and arachnoidal adhesions, to differentiate disc herniations from adhesive processes in the epidural tissue, inflammatory processes, as well as tumor and vascular neoplasms. With some margin of error, MRI can determine the dimensions of the spinal canal and disc herniation. MRI (standard) with high magnetic field strength (1.5 – 3.0 Tesla) is the main method of diagnosis and neuroimaging of degenerative spinal lesions. In recent decades, this type of study has become widespread and decisive. It fully provides an opportunity to judge the changes in the vertebrae, intervertebral discs, ligamentous apparatus, nerve and other structures. Due to the non-invasive nature of the method, it can be performed on an outpatient basis.

• MRI monitoring of the postoperative state of the spine is recommended to be performed no earlier than 3 months after surgical treatment, since the presence of postoperative artifacts reaches 100% on the first day after surgery [39, 40].

le CLoE 4Level of Evidence C (level of reliability of evidence – 4).

Comments: Computed tomography (CT) of the spine is performed in addition to MRI. It allows the diagnosis of bone and cartilage changes in the early stages and the determination of minimal anomalies. CT is also indicated if MRI is impossible (implants made of magnetic metals, cardiac pacemaker, etc.). With the introduction of a contrast agent intrathecally (CT myelography), this method becomes more informative. CT myelography is an invasive research method, which limits its application. When performing CT and CT myelography, it is possible to make three-dimensional reconstructions of spinal segments.

Comments: Plain radiography with functional tests (anteroposterior projection in a standing position, lateral projection in a standing position and with forward and backward bending in a lateral projection) allows obtaining the most complete general characteristics of the bone structure of the lumbosacral spine, identifying spondylolisthesis and hypermobility (instability) of the spinal segment, which may not be detected by magnetic resonance imaging of the spine performed in a horizontal position, determining the height of interbody spaces, arthrosis of the intervertebral joints, formation of interbody osteophytes, identifying developmental anomalies of the vertebrae, lumbarization, and sacralization. Vertical spinal radiography (step-mode or postural) is performed as follows: lateral projection – in a standing position in a normal posture from the cranial vault to the middle third of the femur, the head in a free and comfortable position, hands placed on opposite clavicles; anteroposterior projection – in a standing position in a normal posture from the cranial vault to the middle third of the femur, hands positioned freely along the torso. Vertical spinal radiography is necessary to determine the values of sagittal and frontal balance parameters.

To perform preoperative planning, the SmartPlan Ortho, SmartPlan Ortho 2D preoperative planning system or another software product with similar functions that ensures the achievement of the described preoperative planning result and is included in the Unified Register of Russian Computer Programs and Databases of the Russian Ministry of Digital Development may be used.

Comments: In the presence of clinical and morphological mismatch, there is a need for the most complete and detailed examination of the patient using all available methods. A single diagnostic method, even among highly informative ones, is not always sufficient for orthopedic trauma surgeons or neurosurgeons, which necessitates the use of their combination.

Comments. Computed tomography of the spine is an alternative to lumbar densitometry in terms of determining bone mineral density, especially in patients with degenerative spinal lesions [46, 47]. The threshold value for detecting bone mineral density disorders in patients is an HU (Hounsfield unit) value <135 [48]. HU is a predictor of pedicle and vertebral body screw loosening during metal fixation [49, 50]. When bone mineral density disorders are detected according to computed tomography data, it is necessary to determine the potential benefit of using metal implants, due to the high risk of their loosening and subsequent unsatisfactory clinical outcome

Comments: In a retrospective study, Eno et al. [51] analyzed computed tomography data from 373 individuals without lower back or pelvic girdle pain and detected SIJ degeneration in 65.1% of the subjects, noting marked degeneration in 30.5%. According to a systematic review by Zelle et al. [52] MRI of the sacroiliac joints is indicated to detect early sacroiliitis and neoplastic lesions. However, this method cannot be recommended as a routine diagnostic tool due to the lack of reports on the use of MRI in evaluating patients with SIJ dysfunction. Radionuclide imaging may be used to detect sacroiliitis, stress fractures, or neoplasms involving the SIJ.

Additional imaging studies have a limited role in evaluating pain caused by SIJ pathology, provided there is no tumor in this location, infection, or a history of trauma in the patient. Computed tomography also has limited diagnostic value in SIJ disease due to its low sensitivity and specificity in identifying the pain source. Radiography and MRI may be useful in detecting sacral fractures, tumors, sacroiliitis, and ankylosing spondylitis. MRI can be used to assess sacroiliitis in patients with spondyloarthritis.

2.5 Other Procedures

Comments: A systematic review (Frank J.E. Falco et al.) [53] demonstrated that a diagnostic blockade using a local anesthetic (lidocaine** 1% 0.5 ml single infiltration (no age restrictions for this dosage), bupivacaine** 0.25% 0.5 ml single infiltration (in adults and children aged 12 years and older)) targeting the area of the medial branches of spinal nerves, combined with intra-articular contrast radiography of the intervertebral cartilage, is safe and effective for diagnosing cervical facet syndrome.

Comments: A meta-analysis (Lee CH et al.) [54] demonstrated that the administration of a local anesthetic (lidocaine** 1% 0.75 ml single infiltration (no age restrictions for this dosage), bupivacaine** 0.5% 0.5 ml single infiltration (in adults and children aged 12 years and older)) targeting the area of the medial branches of spinal nerves or intra-articularly, combined with intra-articular contrast radiography of the intervertebral cartilage, was a clinically significant diagnostic method prior to performing RFA.

Comments: In a systematic review (Simopoulos et al.) [55] fluoroscopically guided administration of a local anesthetic into the sacroiliac joint was shown to be safe and to possess good diagnostic value when used for diagnosis after candidate selection based on provocative clinical tests.

Comments: In systematic reviews by L. Manchikanti et al., 2009 and 2013 [56, 57] based on the analysis of 9 studies of adequate methodological quality (AHRQ criteria), the level of evidence (according to U.S. Preventive Services Task Force criteria) for provocative discography was II-2 (at least one well-designed prospective controlled trial with a small sample size). The specificity of the method was 0.94 (95% CI; 0.88–0.98), and the prevalence of discogenic pain among chronic pain syndromes according to discography was 26–39%.

Comments: At the time of writing these clinical guidelines, pressure-controlled discography systems were not available in the Russian Federation. An alternative is analgesic discography—the intradiscal administration of a local anesthetic (use lidocaine** 2% 0.5–1 ml (no age restrictions for this dosage), or bupivacaine** 0.5% 0.5–1 ml (in adults and children aged 12 years and older), or ropivacaine** 0.75% 0.5 ml (in adults only)). In prospective non-randomized studies (R. Derby et al., 2010 and 2012, W. Bartynski and W. Rothfus 2012) [58, 59] comparing various discography protocols, the use of a local anesthetic (either mixed with contrast medium during provocative discography or administered alone without pressure control) did not alter results compared to the reference method, including the incidence of discogenic pain. Disc puncture is an invasive procedure with potential risks of neurological complications, discitis (approximately 1 in 1,000 interventions), and accelerated disc degeneration due to needle trauma and elevated intradiscal pressure. Diagnostic intradiscal interventions should be performed as a last resort, after less invasive procedures.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

Comments: The majority of patients achieve successful conservative therapy (outpatient, inpatient, spa-based) resulting in sustained, long-term remission. In children, conservative treatment is administered according to the adult protocol, adjusted for appropriate drug dosages.

When a patient seeks medical care for pain in the cervical, thoracic, lumbar regions, and/or extremities due to degenerative-dystrophic changes, emergency conservative or surgical care is required in certain cases for hyperalgesic or paralytic forms of radicular syndrome, development of cauda equina syndrome, or acutely developing vertebrogenic compression myelopathy. In the presence of clinical and morphological correlation, planned surgical treatment is indicated to eliminate the substrate compressing the neurovascular structures.

3.1.1 Pharmacotherapy for acute musculoskeletal (nonspecific) low back pain

Comments: A systematic review and meta-analysis (Traeger AC et al., 2015) [62] demonstrated that although individual patient education is not effective for reducing acute nonspecific low back pain, it effectively reassures patients and reduces the number of repeated primary care visits due to low back pain over a year.

Comments: The recommendation is based on data from 2 systematic reviews with meta-analysis, which showed that patients with acute nonspecific low back pain experience a significant reduction in pain after 1 week of NSAID intake; the drugs were prescribed at effective doses for the minimum necessary number of days to reduce the risk of adverse effects (Gianola S. et al., 2022) [63]. There is no reliable evidence indicating the superiority of any single NSAID over others in relieving acute nonspecific low back pain (Wewege MA et al., 2023) [64].

Comments: No significant advantage of paracetamol over placebo has been proven regarding pain reduction and improvement of functional status in patients with acute nonspecific low back pain [65].

Comments: The recommendation is based on data from 3 systematic reviews with meta-analysis and 1 randomized multicenter controlled trial, which provided data regarding the analgesic efficacy of muscle relaxants combined with NSAIDs [63, 66, 67, 68].

Comments: A systematic review and meta-analysis (Calderon-Ospina CA et al., 2020) [69] demonstrated that combination therapy with NSAIDs (using diclofenac** as an example) and B vitamins may have a more effective analgesic effect compared to NSAID monotherapy in acute nonspecific low back pain. However, there is insufficient evidence to recommend this therapy for other types of pain due to a lack of high-quality studies.

Comments: There is no convincing evidence of the superiority of glucocorticoids in acute nonspecific low back pain compared to other drug classes, and due to an increased risk of adverse events [70, 71].

Comments: According to 2 systematic reviews with meta-analysis, there is evidence of an increased risk of adverse events with opioid use compared to other drug classes used for acute nonspecific low back pain [63, 64].

3.1.2 Pharmacotherapy of chronic musculoskeletal (nonspecific) low back pain

Comments: There is no reliable evidence indicating the superiority of any single NSAID over others in relieving nonspecific low back pain. Given that parenteral administration has no advantages in efficacy but is significantly inferior in safety, the use of topical NSAID forms is advisable [72, 73].

Comments: There is a significant reduction in pain and disability 1 week after starting oral NSAIDs [72, 73]. It is recommended to prescribe NSAIDs at effective doses for the minimum necessary number of days to reduce the risk of adverse effects [72-77].

Comments: Results of a systematic review show that paracetamol** does not provide a clinically significant effect in the short term, and the long-term effect of this drug in treating spinal pain remains unknown. Furthermore, a higher risk of abnormal liver function test results was found in patients taking paracetamol**, although the clinical consequences of this are unclear [65, 78]. It has been reported that paracetamol** is ineffective in patients with chronic low back pain [74, 76, 78].

Comments: In clinical studies, these drugs show good efficacy, but adverse reactions and drug interactions may limit their use [79], reducing adherence to pharmacotherapy [76, 77, 80].

Comments: In patients with mild to moderate pain, oral administration of step II opioids (e.g., tramadol**, codeine) can provide effective analgesia without adverse side effects. Only as an alternative and in case of long-term treatment failure in severely ill patients is it advisable to prescribe step III opioids (e.g., morphine, oxycodone) [81, 82]. Opioids should not be considered as first-line therapy for subacute or chronic pain. Expected benefits of therapy must be weighed against risks before initiating treatment.

Comments: According to the results of a systematic review with meta-analysis, there is evidence regarding the efficacy of duloxetine in the treatment of chronic nonspecific low back pain [313].

Comments: Data from a study of amitriptyline** in patients with chronic nonspecific low back pain revealed that efficacy in reducing pain is minimal, but an improvement in patients' functional status is observed [87].

3.1.3 Pharmacotherapy for acute radicular (nerve root) pain

Comments: The recommendation is based on data from 2 systematic reviews with meta-analysis and 1 randomized controlled trial, which provided low- and moderate-quality evidence of the superiority of NSAIDs over placebo in improving functional outcomes and reducing pain intensity in patients with low back pain and radicular leg pain [88-90].

Comments: The recommendation is based on data from 3 RCTs [91-93], which demonstrated that oral or parenteral administration of GCS (prednisolone** at a dose of 60 mg for 3 days followed by a dose taper of 20 mg every 3 days, or methylprednisolone** at a single IV bolus dose of 500 mg or a single IM dose of 160 mg) provided short-term reduction in leg pain intensity. The recommendation is also based on a systematic review with meta-analysis, which found that the use of GCS contributed to an average pain reduction of 12-29 points on a 100-point scale compared to placebo (3.4 points), (p<0.01).

Comments: The recommendation is based on data from 1 randomized clinical trial [94], as well as data from 2 systematic reviews with meta-analysis [95, 96]. The studies failed to demonstrate a significant benefit of the drugs compared to placebo regarding pain reduction and functional outcome improvement in patients with acute radicular pain.

3.1.4 Pharmacotherapy for chronic radicular (nerve root) pain

Comments: The recommendation is based on a prospective, double-blind, randomized controlled trial [97], which established the efficacy of duloxetine in patients with chronic radicular pain.

Comments: According to a meta-analysis, gabapentinoids (gabapentin, pregabalin) do not reduce pain or improve functional status in patients with chronic radicular pain. Moreover, their administration was found to be associated with a significantly higher number of side effects [95]. According to a double-blind, randomized, placebo-controlled trial, pregabalin was found to be ineffective in the treatment of chronic radicular pain, and its administration was associated with a higher frequency of dizziness [94].

3.2. Percutaneous interventions

Interventional procedures are intermediate methods of treating spinal osteochondrosis. According to the target area, they can be divided into interventions in the region of:

- cervical zygapophysial (facet) joints

- thoracic zygapophysial (facet) joints

- lumbar zygapophysial (facet) joints

- sacroiliac joint

- epidural space and spinal nerves in the cervical spine

- epidural space and spinal nerves in the thoracic spine

- epidural space and spinal nerves in the lumbar and sacral spine

- intervertebral disc

3.2.1. Interventional puncture procedures in the cervical zygapophysial (facet) joints

Comments: The results of one randomized and one prospective observational study indicate the efficacy of periodic blockade of the medial branches of the cervical spinal nerves for pain relief from facet joints. Such efficacy persisted for the study duration (2 years), requiring blocks on average 3 times per year, with a duration of effect after a single procedure lasting 17-19 weeks. At the same time, no data were obtained regarding an additional effect of the glucocorticosteroid as an adjuvant to the local anesthetic (lidocaine** 1% 0.5-2 ml [no age restrictions for this dosage] or bupivacaine** 0.5% 0.5-2 ml [in adults and children aged 12 years and older]) [98, 99].

Comments: Studies have shown comparable needle placement accuracy for blockades using ultrasound navigation, along with a shorter procedure time and/or fewer needle passes required (compared to X-ray navigation). However, available RCTs investigated intervention only on the third occipital nerve and the medial branch of the C7 spinal nerve, and pain intensity reduction was not the primary endpoint in any of them. Long-term pain relief outcomes (1, 3, 6 months) were evaluated in only one retrospective study. [100-106].

Comments: At least one RCT and 3 observational studies support this recommendation. Patient selection for radiofrequency denervation was based on an 80-100% reduction in neck pain intensity after two to three X-ray-guided comparative blockades with infiltration of a local anesthetic solution (lidocaine** (ATC: N01BB02) 1-2% 0.3-0.5 ml [no age restrictions for this dosage] or bupivacaine** (ATC: N01BB01) 0.25-0.5% 0.3-0.5 ml [in adults and children aged 12 years and older] and 0.9% sodium chloride 0.3-0.5 ml) and a duration of pain relief of at least the duration of action of the used local anesthetic, with no pain relief when using 0.9% sodium chloride. Radiofrequency denervation resulted in a 58-76% reduction in pain intensity over 9-12 months. [107-110].

Comments: At least two retrospective studies indicate the efficacy of repeat RFD of the zygapophysial joints provided the first denervation was successful and the patient is satisfied with its course and outcome. Diagnostic blocks prior to repeat denervations were not performed by the authors. [111, 112].

Comments: There is sparse and contradictory evidence regarding the medium- and long-term efficacy of intra-articular local anesthetic injections with or without glucocorticosteroids for pain originating from zygapophysial joints of traumatic and non-traumatic etiology. A prospective observational study showed that in 24 (54.5%) out of 44 patients taking opioids, diagnosed with non-traumatic cervical facet joint pain based on comparative blocks, pain reduction of at least 2 points on the verbal numerical rating scale or 50% from baseline was achieved at 1 year. Intra-articular administration of lidocaine** (1% 0.5 mL, there are no age restrictions for this dosage) with or without a glucocorticoid was performed. Furthermore, in 11 of the 24 patients, intra-articular injections had to be repeated with a median interval between the first and second injection of 6 (range 2–52) weeks [115]. All patients with a positive effect reported cessation of opioid use.

3.2.2 Percutaneous interventional procedures in the thoracic zygapophysial (facet) joints

Comments: The results of two randomized and one retrospective observational study indicate the efficacy of periodic blockade with or without glucocorticosteroids of the medial branches of the thoracic spinal nerves for the relief of zygapophysial joint pain. Such efficacy persisted for the duration of the study (2 years) with the need to perform blocks on average 1 to 5 times per year in 80–84% of patients. Another randomized study compared a pain intensity reduction of at least 50% in the medial branch block group in 40% of patients [120, 121].

Comments: This recommendation is supported by data from a randomized trial (Lee D.G., 2018). Results demonstrated a pain intensity reduction of at least 50% in the group receiving X-ray-guided contrast-enhanced intra-articular administration of a local anesthetic (lidocaine** 2% 1 mL, with no age restrictions for this dosage) and a glucocorticoid in 65% of patients.

Comments: The recommendation is based on the results of one randomized clinical trial and two retrospective observational studies utilizing various radiofrequency techniques (bipolar, cooled). The primary endpoint of the randomized trial was to compare chemoneurolysis and radiofrequency denervation (RFD) of thoracolumbar facet joint nerves in patients requiring repeat denervation. The median pain reduction of at least 50% after the first denervation was 10.7 months (range 6.3–12.7 months) and after repeat denervation 10.7 months (range 5.4–24 months). The majority (71%) of patients in another retrospective study underwent bipolar denervation of the cervicothoracic zygapophysial joints. 82% of patients experienced pain relief of at least 50% at 12 months post-procedure. Another retrospective study showed that a mean pain reduction of at least 50% was observed in the medium term from 2 to 6 months after cooled RFD in patients with thoracic zygapophysial joint pain selected based on comparative blocks [122, 123].

3.2.3 Percutaneous interventional procedures in the lumbar zygapophysial (facet) joints

Comments: This recommendation is based on the results of 3 randomized controlled trials, 1 systematic review with meta-analysis based on the analysis of randomized clinical and observational studies on the efficacy of various injections of local anesthetics and glucocorticosteroids for low back pain caused by zygapophysial joint pathology. This procedure leads to a 50% or greater reduction in pain intensity and an improvement in functional status in 80% of patients for a period of 6 to 24 months. If the procedure is effective and pain subsequently recurs, it may be repeated [124-127].

Comments: This recommendation is supported by the results of a retrospective comparative study [128], an observational study [129], and a systematic meta-analysis [130]. Following the procedures, pain intensity significantly decreased for a period of 3–6 months. When using ultrasound navigation, incorrect needle placement is possible, especially in overweight patients; therefore, its use in such patients is appropriate when access to or contraindications for X-ray navigation exist [130].

Comments: The recommendation is supported by a randomized controlled trial [131], a non-randomized controlled comparative study [132], and a double-blind prospective comparative study [133]. The studies investigated the efficacy of fluoroscopically guided intra-articular anesthetic and steroid injections. Data showed a significant reduction in pain intensity for 6–12 months [131-132], including compared to the control group [131], as well as an improvement in functional status [131, 133].

Comments: The recommendation is supported by data from a comparative randomized trial [133], a retrospective comparative study [134], in which the majority of patients maintained the effect of reduced pain intensity and improved functional status for a period of 3 to 6 months following the procedures [133-136]. When using ultrasound guidance, incorrect needle placement is possible, particularly in overweight patients; therefore, its use in such patients is appropriate in cases of limited access or contraindications to X-ray guidance [130].

Comments: This recommendation is supported by at least 2 randomized controlled trials, 1 meta-analysis, and 1 systematic review with meta-analysis [127, 137-139]. Following radiofrequency ablation (RFA), a 50% reduction in pain intensity and an improvement in functional status persisted for 12 months [127, 137-139].

Comments: Retrospective studies evaluating the efficacy of repeat RFD for pain recurrence have demonstrated that when the response to the initial RFD was positive, all repeat RFDs were likewise effective, with a significant reduction in pain intensity averaging 10.5 months in 85% of patients [140, 141].

3.2.4 Minimally invasive interventional procedures in the sacroiliac joint region.

Comment: A systematic review (Kennedy et al.) [142] established a moderate level of certainty regarding the efficacy of intra-articular glucocorticosteroid (GCS) injection under fluoroscopic guidance with a radiopaque contrast agent. A double-blind study (Maugars Y. et al.) [143] demonstrated a significant reduction in pain in the group of patients receiving fluoroscopically guided GCS injections. Prospective randomized controlled trials (Jee et al.) [144] as well as (Soneji et al.) [145] found that fluoroscopic and ultrasound navigation provide equivalent efficacy and safety for intra-articular SIJ injections. However, fluoroscopic navigation is recommended for diagnostic blocks due to its higher precision.

Comment: A randomized placebo-controlled trial by Cohen et al. [146] established the efficacy of SIJ denervation. The duration of the analgesic effect of RFD was up to 6 months. In a randomized placebo-controlled trial of cooled radiofrequency denervation of the sacroiliac joint (Patel et al.), the cooled RFD group showed significant pain reduction and improved quality of life compared to the control group. The results of the cooled RFD persisted for up to 9 months [147].

3.2.5 Minimally invasive interventional procedures in the epidural space and spinal nerves in the cervical spine.

Comments: This recommendation is based on a meta-analysis [148] that included 4 randomized clinical trials [149-152]. Considering the risks of complications associated with epidural blockade, it is rational to perform this procedure if conservative pain therapy is insufficiently effective over several weeks. The average duration of the analgesic effect following the procedure is 3 months. If effective, repeat epidural blocks may be performed up to 2–3 times a year. The use of a transforaminal approach for cervical epidural blocks is discouraged due to the risk of severe neurological complications [153].

Comments: This recommendation is based on a systematic review with meta-analysis [154] including 1 randomized clinical trial [155], 2 prospective observational studies [156, 157], and 1 retrospective study [158]. The duration of the analgesic effect following cervical dorsal root ganglion pulsed radiofrequency ablation can range from 3 to 12 months.

3.2.6 Minimally invasive interventional procedures in the epidural space and spinal nerves in the thoracic spine

Comments: This recommendation is based on a randomized clinical trial [159]. Given the risks of complications associated with epidural blockade, it is rational to perform this procedure if conservative pain therapy is insufficiently effective over several weeks. If effective, repeated epidural blocks can be performed up to 2–3 times a year.

3.2.7 Puncture interventional procedures in the epidural space and spinal nerves in the lumbar and sacral spine.

Comments: This recommendation is supported by at least 3 meta-analyses [160, 161, 164] analyzing from 21 to 39 randomized controlled trials. Depending on the systematic review and meta-analysis, the studies included placebo-controlled or active-controlled RCTs. Patient selection was carried out in accordance with the criteria for treating chronic low back and lower extremity pain in lumbar radiculopathy, with a lack of response to conservative treatment. Indicators of positive dynamics were pain relief and improvement in the patient's functional status. Significant improvement was defined as a 50% or greater reduction in pain and improvement in functional status. Patient follow-up after epidural injections ranged from 3 to 12 months, with a pronounced positive response observed in the first 3 months. In some studies, the epidural injection was repeated after 3 months, noting a cumulative effect. These interventions are performed via various approaches: interlaminar, transforaminal, or caudal, depending on the clinical and imaging picture. All approaches have identical levels of evidence. It is also worth noting that using a mixture of a local anesthetic and a glucocorticosteroid demonstrated higher levels of evidence and a longer-lasting effect in long-term comparisons exceeding 6 months according to RCT data.

Comments: This recommendation is supported by at least two meta-analyses based on active-controlled and double-blind RCTs. These studies [165, 167, 168] compared epidural administration of local anesthetics (LAs) with/without glucocorticoids versus pulsed radiofrequency ablation of the dorsal root ganglia followed by LA administration with/without GCs. Pulsed radiofrequency ablation demonstrated a pronounced long-term positive effect in the form of a greater than 50% reduction in pain and a 50% or greater improvement in functional status according to the Oswestry Disability Index, with the effect persisting for 6-12 months [165, 167]. In the short-term follow-up period (up to 3 months), no statistical differences in efficacy were established between pulsed radiofrequency ablation of the dorsal root ganglia and epidural injection of local anesthetics with/without GCs [166, 169].

3.2.8 Interventional puncture procedures on the intervertebral disc.

Comments: Interventions used to treat discogenic pain target the core mechanisms of its formation. Degenerative changes in the disc are accompanied by inflammation, which sometimes also affects the endplates of adjacent vertebrae. The issue of intradiscal administration of glucocorticosteroids has been addressed in 7 RCTs [170-176], 1 systematic review with meta-analysis [177]; All review papers note high heterogeneity and limited methodological quality of the studies. In the first 2 RCTs [170, 171] patient enrollment was based exclusively on the presence of concordant pain during provocative discography; no data supporting the efficacy of intradiscal steroid administration were obtained. In the studies (Buttermann G.R., 2004; Cao P. et al., 2011)[172, 173] the efficacy of steroids for discogenic pain was evaluated in patients with concordant pain during discography and endplate changes, whereas in the studies (Nguyen C. et al., 2017; Tavares I. et al., 2020)[175, 176] patients were enrolled exclusively based on the presence of inflammatory endplate changes (Modic I). These 4 RCTs confirmed the efficacy of steroids for discogenic pain and Modic type I changes, while the study by (Cao P. et al., 2011) [173] demonstrated the efficacy of steroids in Modic II changes as well. The study by (Yu Y. et al., 2012)[174] included patients with pain associated with single-level disc changes on MRI and negative provocative discography findings, and confirmed the efficacy of steroids compared to placebo. In all works, the duration of the positive effect from administration did not exceed 3 months. The meta-analysis Daste C. et al., 2021 [177] included 5 RCTs (Knot A. et al., 2004; Cao P. et al., 2011; Yu Y. et al., 2012; Nguyen C. et al., 2017; Tavares I. et al., 2020)[171, 173-176]  and confirmed the short-term efficacy of steroids for back pain treatment, although no recommendations regarding patient selection were made.

Comments: One of the proven mechanisms of chronic discogenic pain syndrome is the ingrowth of nerve endings into the inner parts of the annulus fibrosus. A number of radiofrequency ablation techniques targeting these endings have been proposed, differing in the insertion and placement of electrodes within the annulus fibrosus. The IDET (IntraDiscal Electrothermal Therapy) technology is not available in the Russian Federation; there is insufficient evidence for disctrode/flextrode technologies, making intradiscal biacuplasty the only technology for which recommendations can be made.

The evidence base for biacuplasty is represented by two high-level RCTs [178, 179], demonstrating the efficacy of the procedure compared to placebo and conservative treatment, respectively. These studies were included in a systematic review [180] and assigned Level I of evidentiary reliability. An RCT (Juch J.N.S. et al., 2017) [181] obtained different data: biacuplasty combined with physical therapy showed no advantage over isolated physical therapy; however, there are numerous concerns regarding the methodological quality of the study [182, 183]. It is worth noting that in all RCTs, provocative discography was the diagnostic criterion for discogenic pain syndrome (study with Level of Evidence 2 and Grade of Recommendation B).

A number of interventional techniques have been developed for the treatment of patients with intervertebral disc herniations. Their general principle is the percutaneous removal of a small part of the nucleus pulposus (nucleotomy) via mechanical destruction (automated percutaneous lumbar discectomy, DekompressorⓇ and analogs, hydrodiscectomy), laser, or plasma ablation (nucleoplasty). Although it was hypothesized that reducing intradiscal pressure would alleviate discogenic back pain, efficacy has been demonstrated only for radicular pain caused by intervertebral disc protrusion.

Comments: Only 1 RCT has been conducted regarding nucleoplasty (Gerszten P.C. et al., 2010) [184], while for others, only uncontrolled prospective and retrospective studies demonstrating positive results are available. A systematic review [22], conducted during the development of clinical guidelines by the American Society of Interventional Pain Physicians (ASIPP), assigned a sufficient level of evidence (according to the U.S. Preventive Services Task Force criteria) only for nucleoplasty, and limited evidence for all others.

3.3 Surgical Treatment

When performing surgical treatment in patients with degenerative dystrophic spinal changes, one must be guided by the principles of "minimal sufficiency" and "clinical and morphological concordance".

The following types of open surgical interventions exist for degenerative dystrophic spinal changes:

• decompressive

• stabilizing

• corrective

• plastic

• combination of methods

3.3.1 Decompressive surgical interventions.

Comments. Surgical treatment is more effective than conservative therapy in the medium term (1–4 years). The optimal timing for surgical intervention for intervertebral disc herniation is between 6 months and 1 year, which is associated with faster recovery and improved long-term outcomes; surgery earlier than 6 months is indicated when there are strong grounds (severe pain syndrome, progressive neurological deficit). Intervertebral disc herniation removal and intervertebral disc herniation removal using video-endoscopic technologies via various approaches have comparable clinical and radiological outcomes. There is insufficient evidence to recommend the use of fat or biogels in the epidural space to prevent peridural fibrosis for improving clinical outcomes. The use of screw and/or interbody fixation in the surgical treatment of patients with intervertebral disc herniation confers no clinical advantages. Performing screw and/or interbody fixation is associated with a higher risk of perioperative complications, increases the duration and cost of surgical treatment, increases postoperative hospital stay, and involves greater blood loss.

Comments. In the surgical treatment of disc herniations in children, preference should be given to intervertebral disc herniation removal using minimally invasive surgical approaches. The clinical outcomes of surgical treatment in children surpass those in adult patients.

Comments. Surgical treatment of patients with degenerative spinal stenosis is more effective than conservative therapy in both the short- and long-term perspectives. Minimally invasive technologies (using a microscope, endoscope, tubular retractor systems, port systems, etc.) are preferred for decompression, as they help reduce the complication rate and postoperative hospital stay. Microsurgical and endoscopic decompression of intraspinal neurovascular structures via various approaches yield comparable clinical and radiological outcomes. However, these technologies are recommended for use in a multimodal mode as part of the decision-making algorithm. Degenerative stenosis is not an indication for screw and/or interbody fixation, regardless of the presence or absence of spondylolisthesis. The use of screw and/or interbody fixation in degenerative stenosis offers no clinical advantages. Performing screw and/or interbody fixation is associated with a higher risk of perioperative complications, increases the duration and cost of surgical treatment, increases postoperative hospital stay, and involves greater blood loss.

Comments: In patients with cervical intervertebral disc herniations and/or degenerative stenosis manifesting solely as radicular syndrome without myelopathy, clinical outcomes are comparable across different surgical intervention methods: decompression versus decompression with screw and/or interbody fixation. The use of screw and/or interbody fixation for degenerative stenosis and/or disc herniation presenting with radiculopathy at the cervical level confers no clinical advantages. Performing screw and/or interbody fixation is associated with a higher risk of perioperative complications, increases the duration and cost of surgical treatment, increases postoperative hospital stay, and involves greater blood loss.

3.3.2 Stabilizing, corrective, and decompressive-plastic surgical interventions.

• preoperatively identified instability of the spinal motion segment;

• forced resection of one or more supporting columns of the spinal motion segment during surgery;

• the need for deformity correction (segmental, global).

GGR CLOC 5Grade of Recommendation C (Level of Evidence – 5).

Comments: Currently, there is no universally accepted definition of "segmental instability". Indirect morphological signs of segmental instability include: segmental angulation greater than 10° on functional spondylography, translation of the overlying vertebra greater than 3 mm from the initial position on functional spondylograms, Modic type I changes, and facet joint synovitis on MRI data. A mandatory component of segmental instability when making a diagnosis and determining treatment tactics must be a clear connection between morphological changes and clinical manifestations, the so-called axial pain syndrome, upon changes in body position. This presents as intense pain in the affected spine segment, occurring in the upright position and during walking, and subsiding in the supine position. Thus, "segmental instability" is a clinical and radiological concept [96].

Additional facet joint arthrodesis has proven effective when performing decompressive interventions for symptomatic degenerative spine diseases (degenerative central stenosis, foraminal stenosis, lumbar disc degeneration and herniation, facet joint degeneration, spondylolisthesis, osteoarthritis, post-surgical instability) [315].

Interspinous stabilization with decompression yields comparable results to isolated decompression in terms of postoperative pain intensity and disability index; however, in terms of quality of life, treatment cost, operative time, blood loss, and reoperation rate, interspinous fixation performs worse. Compared to screw and/or interbody fixation, interspinous fixation has certain advantages in the form of lower postoperative pain intensity, disability index, operative time, blood loss, and reoperation rate. Although patients' quality of life significantly improves after screw and/or interbody fixation.

360° fixation (circumferential spinal fusion, bilateral pedicle screw and interbody fixation) is the preferred type of arthrodesis compared to 270° fusion (unilateral pedicle screw and interbody fixation) and compared to isolated interbody fusion or isolated posterior (interarticular, interspinous, intertransverse) fusion. There is no convincing evidence of the superiority of reducing degenerative spondylolisthesis and decreasing the degree of its displacement with screw and/or interbody fixation of the affected segment. Long-term clinical and radiological results of screw and/or interbody fixation performed via traditional open approaches or using minimally invasive approaches are comparable. However, blood loss, soft tissue surgical trauma, and the risk of surgical site infection are lower when using minimally invasive approaches [198-200]

Patients' quality of life is significantly correlated with spino-pelvic and global sagittal spinal parameters. In adult patients with suspected spinal deformities, the calculation of the following baseline parameters is necessary: PI, PT, SS, LL, Low LL (L4-S1), C2-HA, segmental LL, PI-LL, SVA. This is required for the correct application of the Schwab, Berjano et al., and Gill classifications. When deciding on the magnitude of correction needed for degenerative lumbar spinal deformity, one should proceed from the fact that it is surgically possible to correct lumbar lordosis and thoracic kyphosis. The use of the following formulas will allow planning the extent of necessary segmental correction [201]:

• LL=0.5PI + 28;

• Low LL (L4-S1) = 2/3LL;

• TK=0,75LL;

• C2-HA – no more than 0 – 2°.

These formulas allow calculating the target indicators of a harmonious sagittal spinal profile and spino-pelvic parameters that should be aimed for during surgical treatment. Restoration of correct segmental relationships in the lumbar spine leads to the normalization of global parameters. When planning surgical correction, preference should be given to the normalization of global sagittal parameters (C2-HA). Achieving target calculated values (according to the proposed formulas) for the purpose of correcting sagittal spinal deformity is a difficult task and is associated with a 50% probability of minor and major complications. In some cases, due to a number of objective reasons (surgical accessibility, peculiarities of the disease course, etc.), achieving the target values is not feasible. Undercorrection is a more favorable outcome than overcorrection regarding postoperative mechanical complications.

Correction of deformities (segmental and/or global) can be achieved using corrective vertebrotomy and/or corrective arthrodesis. It is advisable to use the Schwab F. et al. osteotomy classification from 2015. The authors identified 6 types of osteotomies (Fig. 3). Each type of osteotomy has its own correction capabilities ranging from 5 to 90°.

Figure 3 Schwab osteotomy types.

Corrective arthrodesis can be performed via ventral, lateral, oblique, transforaminal, and posterior approaches. ALIF has the greatest correction capabilities, especially when using implants with an angle greater than 15°, which is preferably performed at the L4-L5 and/or L5-S1 levels (up to 15-20° per single segment). TLIF and PLIF have the lowest correction capabilities (7°). DLIF and OLIF have moderate correction capabilities in the sagittal plane (up to 10°), as well as good correction capabilities in the frontal plane [202].

Correction of deformities in patients with sagittal balance disorders can be performed in several ways:

• solely from the dorsal approach using a combination of various Schwab F. osteotomies at different levels depending on the required correction angle, supplemented if necessary by TLIF or PLIF and mandatory posterior pedicle screw fixation;

• a combination of surgical techniques: ALIF, DLIF, OLIF, TLIF, PLIF, various types of Schwab F. osteotomies, and pedicle screw fixation. This intervention implies a staged approach. All stages can be performed in a single surgical session or in multiple sessions. To date, there is no convincing evidence regarding the determination of the sequence of operation stages, nor is there a universally accepted algorithm of actions on whether to perform these stages in one or multiple surgical sessions.

Literature data indicate the comparability of the correction capabilities of the presented methods. However, using a combination of corrective arthrodeses in conjunction with osteotomies allows achieving a more harmonious sagittal profile [190, 195, 201, 203-207].

The main goal of surgery using implants in children is the relief of pain syndrome and/or neurological disorders. The restoration of spino-pelvic relationships and the formation of an artificial block also play an important role [309].

• vertebrogenic (degenerative stenosis, disc herniation) cervical myelopathy in order to eliminate the pathomorphological substrate of compression;

• the need to correct degenerative deformity (segmental, global).

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: The expediency of surgical intervention for cervical myelopathy is determined by the duration and severity of the clinical manifestations of myelopathy, which are assessed according to the Frankel scale (Appendix G4). If the patient has neurological deficit corresponding to Frankel grades A and B for more than 1 year, surgical treatment is inexpedient due to the hopelessness of restoring lost motor functions[208]In monosegmental stenosis with radiculopathy and myelopathy caused by osteophytes of adjacent vertebral bodies, ossified disc herniation, or ossification of the posterior longitudinal ligament, ventral decompression must be completed with stabilization of the affected FSU. Spinal cord decompression and stabilization of the affected FSUs can be performed via ventral, dorsal, or combined approaches. There is no conclusive evidence of the superiority of clinical and radiological outcomes between cervical arthroplasty and interbody fusion. The choice of stabilization method is determined individually by the surgeon based on ethical and economic considerations. If ventral and dorsal approaches are necessary for decompression, stabilization, and correction, the stages can be performed in either a single surgical session or multiple sessions. In extensive spinal canal stenosis, ventral decompression via corpectomy must be completed with interbody stabilization and fixation of the segments using a ventral plate. Performing a corpectomy of more than 3 adjacent vertebrae is not recommended. In extensive spinal canal stenosis, dorsal decompression (laminectomy with foraminotomy) must be completed with pedicle screw fixation or lateral mass screw fixation, unless a ventral stabilization stage is planned during the same or a different surgical session. The choice of decompression approach (ventral or dorsal) is determined by the anatomical location of the compression substrate. In the presence of a kyphotic cervical spine profile in patients with vertebrogenic myelopathy, a mandatory step of the intervention is the correction and stabilization of the ventral support column via interbody fusion (single-, bi-, or multi-segmental), while decompression can be performed via either ventral or dorsal approaches. In lordotic and straight cervical spine profiles, decompression, stabilization, and correction can be performed exclusively via a dorsal approach. During interbody fusion, the creation or preservation of segmental kyphosis is not permitted. When planning surgical interventions on the cervical spine, it is necessary to calculate the following baseline parameters:

• C2–C7 SVA – 20 mm (maximum 40 mm);

• Segmental angle.

In patients with myelopathy caused by degenerative spinal canal stenosis, decompression (via ventral or dorsal approaches) may be performed as a stage of surgical treatment, which must be completed with stabilization at the level of the affected segment(s). In patients with extensive multisegmental stenosis, without the need for correction of the sagittal segmental or global cervical balance, decompressive laminoplasty may be performed at the affected level [208-214]

3.3.3 Postoperative analgesia

Comments: Multimodal analgesia (MMA) involves the use of multiple analgesic drugs (opioid and non-opioid) with different mechanisms of action, along with non-pharmacological interventions aimed at targeting peripheral and/or central parts of the nervous system. This combination allows for more effective pain management by enhancing the effects of various drugs, which in most cases leads to a reduction in the frequency of prescriptions and/or doses of opioid analgesics. Thus, MMA improves the risk profile of each medication while providing synergistic pain control through various drug classes. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, infiltration anesthesia (single injection or peripheral nerve catheter placement), and opioids.

In contemporary scientific literature, authors emphasize the use of the lowest effective doses of opioids for the shortest possible duration, avoiding the use of extended-release opioids.

3.3.4 Surgical antibiotic prophylaxis

Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [224, 225], the objective of SAP is to achieve bactericidal concentrations of a systemic antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections.

Comments. For patients with an unremarkable allergy history and no significant risk factors for methicillin-resistant staphylococcal colonization, first- and second-generation cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously 30 to 60 minutes prior to skin incision. In case of beta-lactam allergy, a combination of vancomycin** with a fluoroquinolone (ciprofloxacin**, levofloxacin**) administered over at least 60 minutes starting 2 hours prior to the incision, or clindamycin**, should be prescribed. For significant risk factors of methicillin-resistant Staphylococcus aureus (MRS) colonization, the SAP regimen must include an antibiotic with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of the antibiotic is sufficient for effective prophylaxis. For prolonged procedures or massive blood loss, an additional intraoperative dose of the antibiotic should be administered (the estimated time for intraoperative administration is two half-lives after the preoperative dose). Post-wound closure administration of antibiotics in the operating room is unjustified even when drains are present.

Single doses of primary antibacterial drugs for SAP in trauma and orthopedic surgeries: cefazolin** 2 g (for patients weighing ≥120 kg — 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, #vancomycin** 15 mg/kg as a slow IV infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg [225].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments: In case of severe pain syndrome in the acute period, bed rest is recommended for 1-2 days, which promotes muscle relaxation and reduction of intradiscal pressure. Bed rest lasting more than 4 days is not beneficial and may subsequently lead to a worsening of the patient's condition [230-232] Clinical standards of the Australian Commission on Safety and Quality in Health Care [228] recommend maintaining physical activity and do not recommend bed rest for more than 4 days in the management of back pain [223, 233- 235]. Two low-quality RCTs have demonstrated the superiority of physical activity over bed rest [236, 237]. Results of high-certainty randomized trials indicate that physical activity should be initiated a few days after the onset of pain, despite the fact that pain may temporarily increase when physical activity is resumed

Comments: The literature provides limited coverage on orthotic management for vertebrogenic pain, and the available data are advisory in nature.

Clinical guidelines for the treatment of back pain presented by the American Association of Neurological Surgeons (AANS) / North American Spine Society (NASS), based on medium-quality RCTs, recommend wearing corsets during the acute pain period to reduce pain by stabilizing the corresponding spinal motion segment and relaxing the muscles [239-241].

After relief of acute pain, wearing corsets and collars is recommended only during physical labor or prolonged static positioning of the torso or head as a prevention of pain recurrence. Continuous wearing of corsets leads to a decrease in muscle tone and subsequently muscle strength, and consequently a reduction in their stabilizing function [ 226].

Comments:

Almost all publications pay the greatest attention to patient education and rational physical activity as the main methodological approaches to the treatment and prevention of vertebrogenic syndromes. Numerous RCTs have been conducted demonstrating the effectiveness of educational programs compared with exercise therapy, manual therapy, and physical therapy in stabilizing both pain syndrome and spinal function [242-247]. Educational programs are included in care standards for back pain [228]. Proper movement mechanics reduce the load on the spine during daily activities and thereby reduce the risk of pain syndrome. Special educational programs have been developed, referred to in a number of countries as "Back Schools." Compliance with the recommendations presented in them, based on high-quality RCTs, helps avoid overloading spinal structures, which can provoke pain and the progression of degenerative-dystrophic processes [238, 248- 252]. Educational programs or back schools teach not only the correct execution of movement skills in everyday life, but also participation in appropriate physical exercises and sports. It is recommended to maintain daily physical activity as close to normal as possible. During the first week after acute back pain subsides, it is recommended to start with warming up and walking in water, then outdoors, cycling, and exercises involving large muscle groups with a gradual increase in both the load itself and the duration of workouts up to 30 minutes without rest [223, 233, 252- 255].

A rational regimen includes the following recommendations:

1. Do not lift or carry heavy objects, especially with outstretched arms. If it is necessary to lift a heavy object from the floor, you should squat down rather than bend forward. Heavy objects should only be lifted to chest level, and if they need to be lifted higher, you should stand on a stool. If the object is very heavy, outside help must be used. Grocery bags should not exceed 5 kg, and it is better to carry them in both hands.

2. Avoid prolonged sitting. Every two hours of work in a sitting position, take a 2-3 minute pause. During this pause, you can stand up and take a few steps around the room. Standing in a comfortable position (feet shoulder-width apart) with your hands on your lower back, it is recommended to arch backward and hold this position for 30-40 seconds. You should sit up straight on a chair of such a height that your feet are flat on the floor and your knee joints are level with your hip joints. Your back should be pressed against the back of the chair. A special roll or rolled-up towel should be placed under the lower back. The same position should be maintained when driving a car. Without getting up from the chair, you can give your back a rest by leaning forward, wrapping your arms around your knees, and resting your head on them. This position is held for 2 to 5 minutes.

It is advisable to avoid working in a bent position (washing clothes in a bathtub, mopping floors, weeding, etc.). For such work, the workplace should be arranged so that the back remains straight. For example, when hand-washing laundry, place the basin on a high stand; when mopping the floor, use a long-handled mop or get down on all fours.

When performing work that involves prolonged standing (ironing), you should alternately place one foot on a support such as a children's step stool, which helps maintain lumbar lordosis.

During prolonged walking, it is recommended to wear comfortable shoes with medium heels.

3. It is best to sleep on a special mattress lying on your side with bent legs, or on your back with a pillow under your knee joints. In these positions, the back muscles relax and rest well during night sleep.

4. Drafts and hypothermia should be avoided. Do not sit on the cold ground or remain in a wet swimsuit after swimming during your summer vacation.

The cervical spine has its own anatomical and physiological features. Therefore, the following additional recommendations are given:

- positions and working situations involving prolonged flexion of the head should be avoided. For example, when working at a computer, it is recommended to periodically lean back on the chair's backrest and relax your arms, making free swinging movements.

- the cervical spine must not be hyperextended (throwing the head back). If you need to do something on a surface higher than your outstretched arms, you should stand on a stool or ladder. It is best to avoid tasks such as whitewashing the ceiling, hanging curtains, etc.

- do not sleep on a high pillow. It is better to place a roll under the neck.

• to administer medical treatment (injection followed by oral pain relief, prophylactic anti-ulcer and antithrombotic therapy) and physical therapy;

• to avoid loads on the spine (heavy lifting, forward bending, active exercise therapy) [1].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments:In the early postoperative period (7-14 days after radical spine surgeries), rehabilitation measures are aimed at early motor activation of the patient, pain relief, and stimulation of reparative processes in the wound area. To provide a decongestant and analgesic effect on the wound area from the first day after surgery, local cryotherapy is prescribed(A24.01.005.003 Local cryotherapy), from the 2nd day after complete cessation of bleeding, low-intensity laser radiation may be prescribed,pulsed low-frequency electromagnetic field therapy (A17.30.036). In case of severe pain syndrome, percutaneous electrical nerve stimulation is used (A17.24.001 Percutaneous electrical nerve stimulation for diseases of the peripheral nervous system), application of diadynamic currents(A17.03.002 Application of diadynamic currents (DDT therapy) in bone pathology)and sinusoidal modulated currents (A17.03.003 Application of sinusoidal modulated currents (SMT therapy) in bone pathology), drug electrophoresis for bone pathology (A17.03.001), reflexology (A21.03.003 Reflexology for diseases of the bone system).

Recovery of motor activity begins on the first day; verticalization and gait restoration measures are carried out, using verticalizers if necessary. Non-pharmacological rehabilitation is combined with non-steroidal anti-inflammatory and antirheumatic drugs, and glucocorticoids are prescribed according to indications. In the presence of preoperative neurological motor impairments, complex rehabilitation treatment is supplemented with drugs that improve neuromuscular conduction.

Comments: This recommendation is supported by 9 RCTs (1176 patients) deemed sufficiently similar to be pooled for meta-analysis. There is moderate-quality evidence showing a statistically significant effect on pain reduction in comparative studies (compared to both exercise and physical therapy (SMD = -0.28, 95% CI from -0.47 to -0.09, p = 0.004; I 2 = 57%). Among five RCT trials (695 patients), mobilization compared to comparator drugs showed a statistically significant reduction in pain (SMD = -0.20, 95% CI from -0.35 to -0.04; p = 0.01; I 2 = 0%). It was also noted that the effect persists at 3 and 6 months of follow-up.

Comments: This recommendation is based on a systematic review and meta-analysis of 47 RCTs involving a total of 9211 participants. Manipulation produces an effect leading to improved spinal function in the short term, as well as a significant reduction in pain syndrome compared to sham manipulation. Specifically, patients who received manipulative treatment had lower mean VAS scores (p<0.0001).

Comments: The recommendation included 71 articles describing 103 patients after surgical treatment: laminectomy (40%), spinal fusion (34%), and discectomy (29%). Lumbar manipulation was used in 85% of patients, applied 1 year or more after surgery in 66% of cases. In none of the cases were significant results obtained. This recommendation is based on a systematic review with meta-analysis; the certainty of evidence of this review remains low, given that it is based on case reports and case series of patients.

Comments: Scattered contradictory publications describe potential complications associated with manual therapy manipulation techniques.

Comments: This recommendation is based on the results of 25 RCTs with 3096 participants from a Cochrane review. Although there is little convincing evidence that massage is an effective treatment for low back pain (LBP), it was noted that acute, subacute, and chronic LBP show improved pain outcomes with massage only in the short-term follow-up period. Functional improvement is observed in patients with subacute and chronic LBP compared to inactive controls, but only at short-term follow-up [266, 267]. However, the synergistic effect of massage manipulations combined with core muscle strengthening exercises in the treatment of patients with chronic nonspecific low back pain can effectively relieve pain and lower back dysfunction, improve dynamic and static muscle endurance, and have significant short- and long-term effects [268, 269]. Types of massage such as myofascial release and shiatsu have a greater analgesic effect than lymphatic drainage and connective tissue massage [270, 271].

Comments: to eliminate ambiguity in the interpretation and understanding of exercise types, we provide their descriptions:

• Muscle strengthening and endurance-building exercises – exercises designed to restore and increase muscle strength, endurance, and improve the function of individual muscles or muscle groups;

• Specific trunk muscle activation/stabilization exercises - exercises aimed at activating specific deep trunk muscles ("core" muscles – transversus abdominis, multifidus) and superficial ("global") muscles (rectus abdominis, erector spinae) to achieve active stabilization, control, and improved coordination in the lumbar and pelvic region;

• Deep neck muscle activation/stabilization exercises exercises aimed at activating specific deep neck muscles to achieve active stabilization, control, and improved coordination in the head and neck region;

• Motor control exercises (MCE) - motor control exercises aimed at restoring coordination and the efficient use of muscles that support and control the spine through the execution of simple, and as patient skills increase, more complex functional tasks;

• General exercises - exercises aimed at restoring or increasing the strength and endurance of the main muscle groups of the upper/lower extremities and trunk, including flexibility/mobility exercises and aerobic exercises;

• Mobility exercises - exercises aimed at increasing the range of motion in the spine and joints or repeating specific uniform movements to reduce symptom severity;

• Stretching exercises - a set of exercises aimed at developing flexibility and gently stretching the body's muscles;

• Coordination exercises – exercises aimed at developing the ability to perform precise and controlled movements through the synchronous work of different muscle groups;

• Centralization exercises and mechanical diagnosis and therapy methods with a directional preference (McKenzie) – exercises whose selection is based on finding a repeated or sustained movement in a specific direction that causes a reduction, centralization, or elimination of symptoms;

• Aerobic exercises – cardio or cardiorespiratory exercises performed by repeating sequences of light- to moderate-intensity movements over prolonged periods of time;

• Multimodal (complex) exercises - exercises that combine two or more of the specified types of exercises (methods).

Comments: ICF domains that maximally correspond to the patient's functional status can be used, for example:

1. Back pain, including with motor deficit:

• Functions: b28013 Back pain; b7101 Mobility of a single joint; b7108 Mobility of joint functions, other specified;

• Structures: s76002 Lumbar region; s7601 Muscles of trunk; s7602 Ligaments and fascias of trunk;

• Activity and participation: d4108 Changing basic body position (bending, extension, rotation), d450 Walking; d469 Walking and moving around, other specified and unspecified.

2. Back pain with movement control impairment:

• Functions: b28013 Back pain; b7601 Control of complex voluntary movements;

• Structures: s76002 Lumbar region; s7601 Muscles of trunk; s7602 Ligaments and fascias of trunk;

• Activity and participation: d4158 maintaining body position, other specified (maintaining a neutral body position); d4106 shifting the body's center of gravity (shifting body mass from one position to another, standing, sitting, or lying, e.g., shifting weight from one leg to the other in an upright position); d4154 standing (remaining in a standing position for a required period of time, e.g., standing in line); d4153 sitting (remaining in a sitting position, on a seat or on the floor, for a required period of time, e.g., sitting at a desk or table); d450 walking; d469 walking, moving around, and related activity, other specified and unspecified.

3. Low back pain with radiculopathy:

• Functions: b2804 radiating pain in a segment or region;

• Structures: s1201 spinal nerves;

• Activity and participation: d4158 maintaining body position, other specified (maintaining a neutral body position); d4150 lying down (remaining in a lying position for a required period of time, e.g., lying in bed).; d450 walking; d469 walking, moving around, and related activity, other specified and unspecified.

This recommendation is supported by a systematic review based on, among others, 129 RCTs on chronic lower back pain [311]. It indicates that the ICF provides a useful tool and can be applied to define and quantify the use of various techniques within outcome measures. It is also supported by expert consensus recommendations based on preliminary studies, the Delphi method, and empirical data [312].

Comments: This recommendation is supported by 3 systematic reviews. One review using meta-analysis based on 39 RCTs [273]. The meta-analysis showed a reduction in pain levels in the exercise group compared to the control group and groups receiving other treatments. Subgroup analysis showed that stabilization/coordination and muscle strengthening exercises are more effective. A second systematic review based on 14 RCTs provides data supporting muscle strengthening, flexibility, and aerobic exercises for chronic back pain [274]. A systematic review based on 28 RCTs was also considered, which found that specific muscle activation techniques are more effective compared to other exercises, as well as other types of conservative therapy and placebo [275].

Comments: Specific tests are used to diagnose movement control impairment [278]. This recommendation is supported by 1 systematic review based on 11 RCTs, which demonstrated a reduction in pain levels in patients after a course of motor control exercises immediately post-intervention, and improvement in function both immediately post-intervention and at medium-term follow-up [276]. Improvement in function was also noted in 4 of the 11 RCTs. We also considered 1 high-quality RCT analyzing results in 172 patients, where patients with movement impairments showed a better response to motor control exercises than to other types of exercise [277].

Comments: This recommendation is supported by 1 systematic review based on 6 RCTs evaluating short-term (5 RCTs) and medium-term outcomes (3 RCTs) [279]. According to the studies, the McKenzie method demonstrated higher efficacy in the short term compared to other types of conservative therapy, including pharmacotherapy, manual therapy, and oral advice. In 1 RCT, the McKenzie method in addition to oral advice showed greater efficacy compared to manual therapy in patients with chronic back pain [280]. In 1 RCT analyzing data from 154 patients with chronic discogenic radiculopathy, conclusions were drawn in favor of multimodal exercise [280]. The study demonstrated the efficacy of multimodal exercises combined with postural correction in reducing back and leg pain and improving function in both the short and long term. In another RCT involving 54 patients, subgroup analysis demonstrated the efficacy of multimodal exercises, including specific muscle activation exercises, compared to oral advice, specifically a reduction in pain intensity over 10 weeks and an improvement in function over one year [281].

Comments: ICF domains that maximally correspond to the patient's functional status can be used, for example:

1. Neck pain with motor impairments:

• Functions: b28010 head and neck pain, b7101 mobility of several joints;

• Structures: s76000 cervical spine;

• Activity and participation: d4108 changing body posture (moving the head and neck when looking right or left).

2. Neck pain with headache:

• Functions: b28010 head and neck pain;

• Structures: s7103 joints of head and neck, s7104 muscles of head and neck;

• Activity and participation: d4158 maintaining body position (maintaining the head and neck in a flexed position when reading a book and in an extended position when working with a monitor).

3. Neck pain with movement coordination impairment:

• Functions: b7601 Control of complex voluntary movements;

• Structures: s7105 Head and neck ligaments and fascia; s7104 Head and neck muscles;

• Activity and participation: d4158 Maintaining body position, other specified (maintaining a neutral position of the head, neck, and thoracic spine).

4. Neck pain with radiculopathy;

• Functions: b2804 Radiating pain in a segment or region;

• Structures: s1201 Spinal nerves;

• Activity and participation: d4452 Reaching out (Using hands and arms to reach out, touch, and grasp something, e.g., reaching across a desk or table for a book).

Comments: Four main types of neck pain can be distinguished:

• Neck pain with restricted range of motion;

• Neck pain with movement coordination impairment (the mechanism of onset is often associated with a history of whiplash injury or the pain has similar symptoms);

• Neck pain with associated headache;

• Neck pain with radiculopathy.

This recommendation is based on at least 2 RCTs [282, 283].

Comments: This recommendation is supported by at least 3 systematic reviews, including 2 reviews with meta-analysis, which demonstrated the efficacy of these exercises—and particularly combinations of these exercises—for pain reduction and functional improvement [284-286].

Comments: At least 2 systematic reviews support this recommendation. The first included 4,761 articles and 21 RCTs, demonstrating superior outcomes in terms of pain reduction, functional improvement, and better quality of life in groups where these types of exercises were used compared to other groups [287]. The second review, based on 12 RCTs, showed the efficacy of exercises in patients with chronic whiplash syndrome (chronic pain syndrome after whiplash injury), as well as improvement in Dizziness Handicap Inventory scores when performing vestibular rehabilitation exercises [288].

Comments: At least 3 systematic reviews support this recommendation, demonstrating the efficacy of these exercises with changes expressed as pain reduction and functional improvement [284, 289]. One of the reviews demonstrated the greatest efficacy when combined with manual therapy [290].

Comments: To support directional preference exercises, we cite 1 RCT demonstrating a reduction in pain and neck pain-related disability index in both the short and medium term; however, the study does not allow for a definitive conclusion regarding the efficacy of McKenzie exercises [291]. To support the efficacy of various types of exercises for patients with cervical radiculopathy, we also consider 2 systematic reviews with meta-analysis; one of them showed a decrease in pain level according to the VAS and improvement according to the NDI (Neck Disability Index). However, given the heterogeneity of the studies on which these meta-analyses are based, the level of evidence can be regarded as low [284, 292].

Comments: This recommendation is based on the results of 6 RCTs (391 patients), 1 systematic review (11 RCTs, 210 participants; PEDRo score 6.8, level of evidence 1b), and 1 Cochrane review (636 patients). The RCTs showed a significant (30%) reduction in pain and a decrease in the disability index (p<0.05) 4 weeks after treatment with pulsed magnetic fields [293, 294]. The systematic review demonstrated that pulsed electromagnetic fields can reduce pain intensity and improve functional capacity in individuals with low back pain (the pain and disability questionnaire showed an average reduction of 42%) [293]

Comments: This recommendation is based on the results of 4 RCTs (664 patients with acute and chronic low back pain), 3 meta-analyses (22 RCTs, 1433 patients), and 1 Cochrane review (4 RCTs, 224 patients). Meta-analyses showed that the use of low-level laser therapy leads to pain reduction for up to 3–6 months with no adverse effects in nonspecific low back pain, alongside a reduction in disability with a moderate level of evidence [295, 296, 298]. A decrease in pain intensity (p<0.0001) and the Oswestry disability index (p<0.05) was observed at both short-term (2 months) and long-term (12 months) follow-up [297].

Comments: This recommendation is based on the results of 6 RCTs (225 patients with chronic low back pain and 48 volunteers) and 4 meta-analyses (44 RCTs, 2688 patients). The meta-analyses (PEDRo score of 6) revealed a 9–14% regression of chronic low back pain with both transcutaneous electrical nerve stimulation and interferential current (0.36, CI from -0.56 to 1.27, I² = 91%) [299, 300]. Another meta-analysis (16 RCTs, 655 participants) showed similar results, with low back pain reduction occurring both during therapy (p=0.02) and 1–3 months after it (p=0.99) [303]. Moderate-quality evidence is available supporting the use of postoperative electrical stimulation — electrical stimulation increased the likelihood of a successful outcome (absence of complications such as nonunion) by 2.5 times compared to controls (OR=2.53, 95% CI from 1.86 to 3.43, p<0.00001) in patients after surgical spinal fusion [301].

5. Prevention and Dispensary Observation

• follow orthopedic recommendations;

• maintain optimal height-to-weight ratios;

• systematically perform optimal physical activity [1].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Most "spinal" pains could have been prevented by controlling posture, gait, and weight, and maintaining adequate daily physical activity, including sports activity appropriate for age and health. Generally, people decrease physical activity with age, gain weight, and pay no attention to physical exercises, and then even insignificant physical load becomes excessive and traumatic.

Prevention measures for the development and progression of spondylarthritis include:

• weight loss;

• regular accessible and diverse physical activities (medical gymnastics, outdoor walks, fitness, exercise equipment, Nordic walking, etc.);

• rational and balanced diet in terms of composition and caloric value;

• injury prevention;

• proper distribution of load on the spine;

• individual selection of a mattress and pillow;

• wearing orthopedic footwear;

• sanation of infection foci.

• about applied treatment technologies;

• about potential outcomes of surgical treatment;

• about the need for further medical rehabilitation.

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

6. Organization of Medical Care

Indications for emergency hospitalization in a medical organization:

• hyperalgesic form of radicular syndrome;

• cauda-medullary syndrome;

• rapidly developing myelopathy;

• paralyzing sciatica.

Indications for scheduled hospitalization in a medical organization:

• radicular pain syndrome and/or antalgic scoliosis resistant to conservative therapy for 4–6 weeks;

• radiculopathy with progressive neurological deficit (paresis of 4 points or less);

• neurogenic intermittent claudication.

Indications for admission to the day hospital:

• radicular pain syndrome, local pain syndrome (in case of previously unperformed conservative treatment, or lack of effect from outpatient therapy for 6 weeks).

Indications for discharging a patient from a medical organization:

• completion of surgical treatment or its stage(s) in multi-stage intervention.

Indications for patient discharge from the day hospital:

• Completed course of rehabilitation treatment

7. Additional Information

As potential outcomes of surgical treatment, it is advisable to use the classification [305, 306]:

• Complication - any deviation from the normal postoperative course that is not intrinsic to the procedure itself and is not a consequence of treatment;

• Failure to cure - diseases and conditions that remain unchanged after surgery;

• Sequelae are changes inherent to the intervention; they are inevitable after surgery.

According to this classification, explaining potential outcomes to the patient allows them to thoroughly assess the necessity and benefit of the proposed surgical intervention, while helping the physician avoid ambiguity in controversial situations.

Complications should be classified into three groups: specific, technical, and general.

Comments. The Clavien-Dindo classification for postoperative complications includes 6 grades [305]: Mild - only minor bedside procedures are required, such as the placement of intravenous and urinary catheters (A11.12.001 Catheterization of subclavian and other central veins, A11.12.002 Catheterization of cubital and other peripheral veins, A11.28.007 Urinary bladder catheterization). Physiotherapy and the following medications are permitted: antiemetics, analgesics, diuretics, and solutions affecting the water-electrolyte balance; Moderate - pharmacological treatment with drugs other than those permitted for mild complications is required, such as systemic antibacterial drugs. This also includes blood transfusion (A18.05.012 Blood transfusion) and total parenteral nutrition; Severe (intervention without general anesthesia*) - endoscopic, invasive procedure, or re-operation without general anesthesia is required; Severe (surgery under general anesthesia) - surgery under general anesthesia is required; Severe (systemic organ failure **); Death (postoperative death).

* For example: wound revision using hypnotics and sedatives and/or local anesthesia.

** Such complications can usually be managed in an intensive care unit, but in some cases, patients with less severe complications may also be admitted to the intensive care unit. For intraoperative complications, it is recommended to use the Stava classification. Three classes of complications are distinguished: Class I — errors without consequences; Class II — errors with immediate recognition and correction; Class III — unrecognized errors leading to significant negative consequences [307].

The Clavien-Dindo classification has excellent intra- (kappa>0.8) and inter-observer reliability (kappa>0.8) in adult spinal surgery [310].

Intra- and postoperatively, after decompressive and decompression-stabilization surgical interventions, the following specific complications may develop: dural tear, postoperative cerebrospinal fluid leak; onset or worsening of neurological deficit (motor impairments, sensory disturbances, pelvic organ dysfunction; epidural hematoma; screw malposition and implant migration; vertebral body fracture; hardware failure; surgical site infections [316-318].

Surgical complications arising in operated patients may necessitate re-operation.

7.2 Features of diagnosis and surgical treatment of pain and/or neurological syndromes in pregnant women

Comments. Spine MRI represents the first-line and safest diagnostic tool for pregnant women suffering from spinal disorders, allowing for a non-invasive and detailed examination of the spine.

Comments. Decompressive surgery (microdiscectomy) for disc herniation in pregnant women is the preferred, highly effective, and safe method that does not negatively affect the course of pregnancy, labor, or the health of the child [320, 321]; decompression-stabilization interventions are not recommended as they may lead to adverse fetal outcomes [320]. Endoscopic discectomy may be considered as an alternative to traditional microdiscectomy. The most appropriate timing and patient positioning for surgery are chosen based on the gestational age and location of the pathology [319].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Krylov Vladimir Viktorovich, Academician of the Russian Academy of Sciences, DSc in Medicine, Professor, Honored Scientist of the Russian Federation, Head of the Department of Fundamental Neurosurgery, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Chief Researcher, Department of Emergency Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine of the Moscow Healthcare Department.

2. Usachev Dmitry Yuryevich, Academician of the Russian Academy of Sciences, DSc in Medicine, Professor, Director of the Burdenko National Medical Research Center of Neurosurgery of the Russian Ministry of Health and Head of the Reconstructive Surgery Group for Main Cerebral Arteries at the 4th Neurosurgical Department (Endovascular Neurosurgery).

3. Krutko Alexander Vladimirovich, DSc in Medicine, Neurosurgeon, Leading Researcher, Head of Traumatology and Orthopedics Department No. 12, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov (Moscow).

4. Konovalov Nikolai Alexandrovich, DSc in Medicine, Professor, Corresponding Member of the Russian Academy of Sciences, Deputy Director for Research, Head of the Spinal Neurosurgery Department, Burdenko National Medical Research Institute of Neurosurgery of the Ministry of Health of the Russian Federation, President-Elect of the Russian Association of Spine Surgeons, Board Member of the Association of Neurosurgeons of Russia, Board Member of the European Association of Neurosurgical Societies, Laureate of the Government Prize of the Russian Federation (Moscow).

5. Nazarenko Anton Gerasimovich, Professor of the RAS, DSc in Medicine, Director of the National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health.

6. Grin Andrei Anatolyevich, DSc in Medicine, Professor, Corresponding Member of the Russian Academy of Sciences, Chief Neurosurgeon of the Moscow Healthcare Department, Head of the Scientific Department of Emergency Neurosurgery, Sklifosovsky Research Institute for Emergency Medicine of the Moscow Healthcare Department, Professor at the Department of Neurosurgery and Neuroreanimation, Yevdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of the Russian Federation (Moscow).

7. Baykov Evgeny Sergeevich, PhD in Medicine, Neurosurgeon at Traumatology and Orthopedics Department No. 12, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov (Moscow).

8. Leonova Olga Nikolaevna, PhD in Medicine, Scientific Secretary of the National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov (Moscow).

9. Genov Pavel Gennadievich, DSc in Medicine, Anesthesiologist-Resuscitator, President of the Association for Interventional Pain Treatment (AIPT), Member of the Pain Treatment Committee of the Federation of Anesthesiologists and Resuscitators, Head of the Department for the Treatment of Patients with Chronic Pain Syndromes, City Clinical Hospital No. 52 of the Moscow Healthcare Department (Moscow).

10. Badalov Nazim Gadzhibala ogly, DSc in Medicine, Chief Researcher, Federal Clinical Research Center of Medical Rehabilitation and Balneology of the Federal Medical-Biological Agency, Professor at the Department of Restorative Medicine, Balneology and Rehabilitation, Sechenov First Moscow State Medical University (Moscow).

11. Abdulkina Natalia Gennadievna, DSc in Medicine, Deputy General Director for Science, Federal Clinical Research Center of Medical Rehabilitation and Balneology of the Federal Medical-Biological Agency (Moscow).

12. Averyanov Dmitry Alexandrovich, PhD in Medicine, Anesthesiologist-Resuscitator, ABIA New Clinic LLC (Saint Petersburg). Volkov Ivan Viktorovich, DSc in Medicine, Neurosurgeon, Head of the Neurosurgery Department, Clinical Hospital "Russian Railways-Medicine" (Saint Petersburg).

13. Vostretsova Yulia Vladimirovna, Physical and Rehabilitation Medicine (PRM) Physician, Anesthesiologist-Resuscitator at the Department for the Treatment of Patients with Chronic Pain Syndromes, City Clinical Hospital No. 52 of the Moscow Healthcare Department, Member of the Association for Interventional Pain Treatment (AIPT) (Moscow).

14. Gerasimenko Marina Yuryevna, DSc in Medicine, Professor, Head of the Department of Rehabilitation, Sports Medicine and Medical Rehabilitation, Russian Medical Academy of Continuous Professional Education (RMAPO), Honored Scientist of the Moscow Region (Moscow).

15. Glebov Maxim Vladimirovich, PhD in Medicine, Neurologist, Scientific Secretary of the Association for Interventional Pain Treatment (AIPT), Head of the Day Hospital, Buyanov City Clinical Hospital (Moscow).

16. Goryacheva Ksenia Valerievna, Neurologist at the Department for the Treatment of Chronic Pain Syndromes, Yudin City Clinical Hospital, Moscow, Member of the Association for Interventional Pain Treatment (AIPT) (Moscow).

17. Gushcha Artem Olegovich, DSc in Medicine, Professor of the RAS, Neurosurgeon, Head of the Neurosurgery Department with Endovascular and Vascular Surgery Group, Research Center of Neurology, Vice-President of the Interregional Organization "Association of Spine Surgeons" (Moscow).

18. Eremushkin Mikhail Anatolyevich, DSc in Medicine, Professor, Head of the Medical Rehabilitation Department, National Medical Research Center for Therapy and Preventive Medicine of the Russian Ministry of Health (Moscow).

19. Koshelev Ruslan Viktorovich, DSc in Medicine, General Director, Federal Clinical Research Center of Medical Rehabilitation and Balneology of the Federal Medical-Biological Agency (Moscow).

20. Miryutova Natalia Fedorovna, DSc in Medicine, Professor, Head of the Neurological Department, Tomsk Research Institute of Balneology and Physiotherapy, Branch of the Federal Clinical Research Center of Medical Rehabilitation and Balneology of the Federal Medical-Biological Agency of Russia (Moscow).

21. Novikov Yury Olegovich, Neurologist, Osteopath, DSc in Medicine, Professor at the Department of Neurosurgery and Medical Rehabilitation, Bashkir State Medical University (Ufa).

22. Sorokovikov Vladimir Alekseevich, MD, Professor, Director of the Irkutsk Scientific Center of Surgery and Traumatology (INTSHT), Head of the Department of Traumatology, Orthopedics and Neurosurgery at ISGMAPO (Irkutsk).

23. Sharinova Irina Anatolyevna, Cand. Sc. (Med.), Neurologist at the Department for the Treatment of Patients with Chronic Pain Syndromes, City Clinical Hospital No. 52 of the Moscow Healthcare Department, Member of the Association for Interventional Pain Treatment (AIPT) (Moscow).

24. Yakhyaev Dzhambulat Muratbekovich, Anesthesiologist-Resuscitator at the Department for the Treatment of Patients with Chronic Pain Syndromes, City Clinical Hospital No. 52 of the Moscow Healthcare Department, Member of the Association for Interventional Pain Treatment (AIPT) (Moscow).

25. Kaprovoy Stanislav Vyacheslavovich, Neurosurgeon, Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation.

The authors declare no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. neurosurgeons;

2. anesthesiologists-intensivists;

3. trauma and orthopedic surgeons;

4. neurologists;

5. rheumatologists;

6. general practitioners (internal medicine);

7. district general practitioners;

8. general practitioners (family physicians);

9. reflexologists;

10. physical and rehabilitation medicine physicians;

11. physiotherapy and exercise therapy physicians;

12. manual therapy physicians;

13. osteopaths.

Methods used for evidence collection/selection:

Search in electronic databases.

Methods used to assess the quality and strength of evidence:

Significance assessment according to tables P1, P2, and P3.

Expert consensus.

Table A1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table P2. Scale for assessing the levels of reliability of evidence (LRE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitation interventions)

Table P3. Levels of Evidence (LoE) grading scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Working Group.

For the final edition and quality control, the clinical guidelines were re-analyzed by members of the working group, who concluded that all comments and feedback from experts were taken into account, and the risk of bias during the development of the guidelines was minimized.

Appendix A3. Reference Materials

These clinical guidelines have been developed taking into account the indications and contraindications, routes of administration, and doses of medicinal products in accordance with the instructions for medical use contained in the State Register of Medicinal Products – www.grls.rosminzdrav.ru

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

If pain occurs in one or more spinal regions, with or without radiation to one or more limbs, weakness, numbness in one or more limbs, or pelvic organ dysfunction, the patient must consult a district general practitioner (or call an emergency or ambulance team if necessary), who, based on the anamnesis, complaints, and clinical examination, will decide on conservative treatment or refer the patient to a neurologist.

Based on the anamnesis, complaints, and clinical examination, the neurologist will decide on conservative treatment, additional instrumental examinations (radiography, MRI, CT, etc.), and, if necessary, refer the patient to a neurosurgeon or trauma and orthopedic surgeon on a scheduled or emergency basis.

Based on the anamnesis, complaints, clinical examination, and additional diagnostic data, the neurosurgeon or trauma and orthopedic surgeon will determine the need for surgical intervention for the identified spinal pathology. If surgical treatment is necessary, it will be performed within a timeframe and scope proportional to the identified pathology and its clinical manifestations.

Following surgical treatment, the patient is discharged to their place of residence for postoperative rehabilitation.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Visual Analog Scale (VAS), Numeric Rating Scale (NRS)

Russian title: Visual Analog Scale (VAS), Numeric Rating Scale (NRS)

Original title: Visual Analog Scale, Numeric Rating Scale (NRS)

Source:

A.Williamson, B. Hoggart: Pain: a review of three commonly used pain rating scales. Journal of Clinical Nursing. 14:798-804 2005.

Use of scales and questionnaires in vertebrology / V. A. Byvaltsev, E. G. Belykh, V. A. Sorokovikov, N. I. Arsentyeva // S.S. Korsakov Journal of Neurology and Psychiatry. – 2011. – Vol. 111. – No. 9-2. – P. 51-56.

Type – assessment scale

Purpose: assessment of pain intensity

Contents:

Visual Analog Scale (10 cm (100 mm) line)

Key: The VAS is a 10 cm (100 mm) line on which the patient is asked to make a mark corresponding to the intensity of pain experienced at the present moment (или over a certain period, e.g., the last week). The patient chooses between "no pain" and "worst imaginable pain". The distance between the start of the scale ("no pain") and the patient's mark is then measured in centimeters, which are converted into points (1 cm = 10 mm = 1 point).

Numeric Rating Scale (a series of numbers from 0 to 10)

Key: The NRS is a series of numbers (scores) from 0 to 10, where 0 corresponds to no pain and 10 corresponds to worst imaginable pain. The patient is asked to choose a number from 0 to 10 that, in their opinion, corresponds to the pain intensity experienced at the present moment (or over a certain period, e.g., the last week).

Appendix G2. Oswestry Disability Index

Russian title: Oswestry Questionnaire

Original title: The Oswestry low back pain disability questionnaire.

Sources:

Fairbank J.C., Couper J., Davies J.B., et al. The Oswestry low back pain disability questionnaire // Physiotherapy. 1980. Vol. 66. P. 271–273.

Bakhtadze M.A., Bolotov D.A., Kuzminov K.O. Low back pain disability index (Oswestry questionnaire): assessment of reliability and validity of the Russian version. Manualnaya Terapiya, 2016.-N 4.-P.24-33.

Cherepanov V.A. Russian version of the Oswestry disability index: cultural adaptation and validity. Hirurgia Pozvonochnika. 2009;(3):93–98. Type – questionnaire Purpose: Assessment of the degree of functional impairment (disability) in chronic lower back pain

Type – questionnaire

Purpose: quality of life assessment

Contents:

SECTION 1. Pain intensity

• I have no pain at the moment.

• The pain is very mild at the moment.

• The pain is moderate at the moment.

• The pain is fairly severe at the moment.

• The pain is very severe at the moment.

• The pain is as severe as it could be / so severe that it is hard to imagine.

SECTION 2. Personal care (e.g., washing, dressing)

• I can look after myself normally without extra pain.

• I can look after myself normally, but it is very painful.

• It is painful to look after myself, and I am slow and careful.

• I need some help to look after myself, but manage most of my personal care.

• I need help every day in most aspects of self-care.

• I do not get dressed, wash with difficulty and stay in bed.

SECTION 3. Lifting

• I can lift heavy weights without extra pain.

• I can lift heavy weights, but it gives extra pain.

• Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table).

• Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.

• I can lift only very light weights.

• I cannot lift or carry anything at all.

SECTION 4. Walking

• Pain does not prevent me from walking any distance.

• Pain does not prevent me from walking more than 1 kilometer.

• Pain prevents me from walking more than 500 meters.

• Pain prevents me from walking more than 100 meters.

• I can only walk with the help of a cane or crutches.

• I spend most of my time in bed and am forced to crawl to the toilet.

SECTION 5. Sitting

• I can sit in any chair as long as I like.

• I can sit as long as I like only in my favorite chair.

• Pain prevents me from sitting for more than 1 hour.

• Pain prevents me from sitting for more than 1/2 hour.

• Pain prevents me from sitting for more than 10 minutes.

• Pain prevents me from sitting at all.

SECTION 6. Standing

• I can stand as long as I want without much pain.

• I can stand as long as I want, but it increases the pain.

• Pain prevents me from standing for more than 1 hour.

• Pain prevents me from standing for more than 1/2 hour.

• Pain prevents me from standing for more than 10 minutes.

• Pain prevents me from standing at all.

SECTION 7. Sleeping

• My sleep is never disturbed by pain.

• My sleep is rarely interrupted by pain.

• Because of pain, I sleep less than 6 hours.

• Because of pain, I sleep less than 4 hours.

• Because of pain, I sleep less than 2 hours.

• Pain prevents me from sleeping at all.

SECTION 8. Sex life (if applicable)

• My sex life is normal and causes no extra pain.

• My sex life is normal, but causes some extra pain.

• My sex life is nearly normal, but is very painful.

• My sex life is severely restricted by pain.

• My sex life is nearly absent due to pain.

• Pain prevents any sex life at all.

SECTION 9. Social life

• My social life is normal and gives me no extra pain.

• My social life is normal, but increases the degree of pain.

• Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., sports, dancing, etc.

• Pain has restricted my social life and I do not go out as often.

• Pain has restricted my social life to my home.

• I have no social life because of pain.

SECTION 10. Traveling

• I can travel anywhere without pain.

• I can travel anywhere, but it gives me extra pain.

• Pain is bad, but I manage journeys over 2 hours.

• Pain restricts me to journeys of less than 1 hour.

• Pain restricts me to necessary journeys under 30 minutes.

• Pain prevents me from traveling except to receive medical attention.

Key: The Oswestry questionnaire consists of 10 sections. In each section, the first answer has a minimum score of (0), and the subsequent answers score 1, 2, 3, 4, and 5 points respectively. When all 10 sections are completed, the Oswestry index is calculated as follows: (total score / 50 [maximum possible score]) × 100 =. If one of the sections is not completed or cannot be assessed (e.g., sex life), the Oswestry index is calculated as follows: (total score / 45 [maximum possible score]) × 100 =. The higher the index, the more significant the disability. The questionnaire can also be used to assess the patient's condition over time, for example, during therapy.

Appendix G3. EQ-5D Health Questionnaire

Russian title: EQ-5D Quality of Life Questionnaire

Original title: European Quality of Life Questionnaire (EQ-5D)

Source:

Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann Med. 2001 Jul;33(5):337-43. doi: 10.3109/07853890109002087. PMID: 11491192.

Brooks R, Boye KS, Slaap B. EQ-5D: a plea for accurate nomenclature. J Patient Rep Outcomes. 2020 Jul 3;4(1):52. doi: 10.1186/s41687-020-00222-9. PMID: 32620995; PMCID: PMC7334333.

Russian population health-related quality of life indicators calculated using the EQ-5D-3L questionnaire / E. A. Alexandrova, A. R. Khabibullina, A. V. Aistov [et al.] // Siberian Scientific Medical Journal. – 2020. – Vol. 40. – No. 3. – P. 99-107. – DOI 10.15372/SSMJ20200314.

Type: questionnaire

Purpose: quality of life assessment

Contents:

Please tick ONE box in each of the sections below. Choose the statements that best describe your health state TODAY.

1) Mobility

• I have no difficulties in walking

• I have some difficulties in walking

• I am confined to bed

2) Self-care

• I have no difficulties with self-care

• I have some difficulties washing or dressing myself

• I am unable to wash or dress myself

3) Usual activities (e.g. work, study, housework, family or leisure activities)

• I have no difficulties with my usual activities

• I have some difficulties with my usual activities

• I am unable to perform my usual activities

4) Pain / discomfort

• I have no pain or discomfort

• I have moderate pain or discomfort

• I have extreme pain or discomfort

5) Anxiety / Depression

• I am not anxious or depressed

• I am moderately anxious or depressed

• I am extremely anxious or depressed

6) We would like to know how you rate your health TODAY.

Key: EQ-5D is a standardized instrument for assessing a respondent's quality of life:

(a) as a health profile – five questions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), each with three levels of problem severity, and

(b) a score obtained using the visual analogue scale EQ–VAS.

Appendix G4. Frankel Neurological Scale

Source: Frankel H.L. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia / H.L. Frankel, D.O. Hancock, G. Hyslop, J. Melzak, L.S. Michaelis, G.H. Ungar, J.D. Vernon, J.J. Walsh // Paraplegia. – 1969. – Vol. 3, № 7. – P. 179–192.

Type – assessment scale

Purpose: Assessment of the neurological status of patients

Content: The scale contains 5 classes A, B, C, D, E, which reflect the severity of the loss of function of the spinal cord and its roots.

Key:

Appendix G5. Neck Pain Disability Index

Russian name: Neck Disability Index

Original name: Neck Disability Index (NDI)

Source:

Steinhaus ME, Iyer S, Lovecchio F, Stein D, Ross T, Yang J, Lafage V, Albert TJ, Kim HJ. Which NDI domains best predict change in physical function in patients undergoing cervical spine surgery? Spine J. 2019 Oct;19(10):1698-1705. doi: 10.1016/j.spinee.2019.06.006. Epub 2019 Jun 15. PMID: 31207316.

The Neck Disability Index-Russian Language Version (NDI-RU): A Study of Validity and Reliability / M. A. Bakhtadze, K. O. Kuzminov, D. A. Bolotov [et al.] // Spine. – 2015. – Vol. 40. – No 14. – P. 1115-1121. – DOI 10.1097/BRS.0000000000000880.

Type – questionnaire

Purpose – assessment of disability. NDI is an analogue of ODI, but is focused on assessing functional impairment caused by cervical spine pathology. It also consists of ten questions regarding pain-related disability and includes items such as headaches, concentration problems, reading problems, and sleep disturbances.

Contents:

Neck pain intensity.

• I have no neck pain at the moment.

• I have very mild neck pain at the moment.

• I have moderate neck pain at the moment.

• I have fairly severe neck pain at the moment.

• I have very severe neck pain at the moment.

• I have the worst neck pain imaginable at the moment.

Self-care (washing, dressing, etc.).

• I can look after myself normally without extra neck pain.

• I can look after myself normally with some neck pain.

• Looking after myself causes neck pain, and I have to be slow and careful.

• I need some help, but I manage most of my personal care myself.

• I need daily help to be able to look after myself in most ways.

• I cannot dress myself, I wash with difficulty, and I stay in bed.

Lifting.

• I can lift heavy weights without extra neck pain.

• I can lift heavy weights with some neck pain.

• Neck pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g., on a table.

• Neck pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.

• I can lift only very light weights.

• I cannot lift or carry anything at all.

Reading (including computer screen).

• I can read as much as I want to without neck pain.

• I can read as much as I want to with slight neck pain.

• I can read as much as I want to with moderate neck pain.

• I cannot read as much as I want to because of moderate neck pain.

• I cannot read as much as I want to because of severe neck pain.

• I cannot read at all because of neck pain.

Headache.

• I have no headaches at all.

• I have slight headaches occasionally.

• I have moderate headaches occasionally.

• I have moderate headaches frequently.

• I am frequently troubled by severe headaches.

• I have a constant headache.

Concentration.

• I can concentrate fully without any difficulty.

• I can concentrate fully with slight difficulty.

• To concentrate, I need to make a considerable effort.

• I find it quite hard to concentrate.

• I find it extremely hard to concentrate.

• I cannot concentrate at all.

Work.

• I can do as much work as I want with no neck pain at all.

• I can do as much work as I want with slight neck pain.

• I can do as much work as I want with moderate neck pain.

• I cannot do as much work as I want because of moderate neck pain.

• Because of severe neck pain, I can only do a minimum amount of work.

• Because of severe neck pain, I cannot do any work at all.

Driving.

• I can drive my car without any neck pain.

• I can drive as much as I want with slight neck pain.

• I can drive as much as I want with moderate neck pain.

• I cannot drive as much as I want because of moderate neck pain.

• Because of severe neck pain, I can drive only with extreme difficulty.

• Because of neck pain, I cannot drive at all.

Sleeping.

• I have no trouble sleeping.

• My sleep is slightly disturbed (less than 1 hour of sleeplessness) because of neck pain.

• My sleep is mildly disturbed (1-2 hours of sleeplessness) because of neck pain.

• My sleep is moderately disturbed (2-3 hours of sleeplessness) because of neck pain.

• My sleep is greatly disturbed (3-5 hours of sleeplessness) because of neck pain.

• My sleep is completely disturbed (5-7 hours of sleeplessness) because of neck pain.

Recreation.

• I am able to engage in all my recreational activities with no neck pain at all.

• I am able to engage in all my recreational activities, with some neck pain.

• I am able to engage in most, but not all, of my usual recreational activities because of neck pain.

• I am able to engage in a few of my usual recreational activities because of neck pain.

• I can hardly do any recreational activities because of neck pain.

• I cannot do any recreational activities at all because of neck pain.

Key: This questionnaire is designed to help us understand how much your neck pain has affected your ability to manage everyday life. Please mark one statement in each section that most closely matches your condition today.

The questionnaire contains 10 sections in total, and each section contains 6 statements. Each statement is assigned a score from 0 to 5, where the first statement corresponds to 0 and the last to 5. For example, the statement in the first section "the neck pain is currently moderate" corresponds to 2 points, and "the neck pain is currently quite severe" corresponds to 3 points. After the patient has completed the questionnaire, the total score is calculated by summing the scores for each section. Then, the degree of disability is determined. Disability can be assessed in points or as a percentage. Disability in points is evaluated on a scale from 0 to 50, since the minimum possible score is 0 and the maximum is 50. For example, if a patient has completed all 10 sections and the total score is 16, this means their disability is 16 points. Sometimes patients skip one of the sections, most commonly the "Driving" section (typically patients who rely primarily on public transport). In such cases, disability is assessed as a percentage. To do this, the sum of the scores is divided by 45 (the maximum possible score when completing 9 sections) and multiplied by 100%. For instance, if after completing 9 sections the score is 16, then 16/45 × 100% = 35.55%. Rounding to the nearest whole number gives 36%. Interpretation of results in points: 0–4 points = no disability; 5–14 = mild disability; 15–24 = moderate disability; 25–34 = severe disability; > 35 = complete disability. Interpretation of results as a percentage: 0%–9% = no disability; 10%–29% = mild disability; 30%–49% = moderate disability; 50%–69% = severe disability; > 70% = complete disability.

Appendix G6. Assessment of cardiovascular risk of surgery

Notes and abbreviations:

CVD – cardiovascular disease (coronary artery disease, cerebrovascular disease, peripheral artery disease, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies);

CVRF – cardiovascular risk factors (arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of premature cardiovascular disease (<55 years for men and <65 years for women);

FS – functional status (patient's ability prior to injury to ascend 2 flights of stairs independently without stopping).

rRCRI - reconstructed RCRI index (See Appendix G.2);

* - regional vascular center or specialized cardiological department.