The Impact of Preoperative Central Sensitization and Novel Mitigation Strategies on Outcomes Following Spinal Surgery: A Comprehensive Narrative Review.

Abstract

Central sensitization (CS) is heightened central nervous system responsiveness to nociceptive input and contributes to the transition from acute to chronic pain. Although increasingly recognized as a predictor of suboptimal outcomes after spinal surgery, no prior review has been synthesized the associations between preoperative CS, underlying mechanisms, and potential perioperative mitigation strategies in spine surgery. This narrative review searched PubMed, Embase, Ovid, the Cochrane Library, and Google Scholar through September 2025 for studies examining preoperative CS-primarily diagnosed using the Central Sensitization Inventory (CSI), Quantitative Sensory Testing (QST), or related tools-in adults undergoing elective spinal surgery. Eleven studies met inclusion criteria, spanning from lumbar disk herniation to cervical myelopathy. Higher preoperative CSI scores (especially ≥40) and abnormal QST findings (reduced pressure pain thresholds, increased temporal summation, impaired conditioned pain modulation) were consistently associated with worse postoperative outcomes, including greater pain intensity, increased disability, poorer quality of life, elevated depressive symptoms, and longer hospital stays. However, leg pain relief after decompression appeared less influenced by CS status in some cohorts. CS prevalence ranged from 10-20% in preoperative populations, with risk factors including prolonged symptom duration, visceral adiposity, pain catastrophizing, and revision surgery. Persistent nociceptive input from degenerative pathology promotes neuroplastic amplification and impaired descending inhibition. Emerging evidence suggests CS may be modifiable: perioperative pain neuroscience education (PPNE) improves CS scores-particularly in high kinesiophobia subgroups-and animal models indicate that intraoperative neuromodulation may decrease postoperative CS development. Preoperative CS screening (e.g., CSI ≥40) should be included into surgical risk assessment . Targeted prehabilitation (PPNE plus exercise), weight optimization, multimodal analgesia, and exploration of intraoperative neuromodulation are promising strategies to mitigate CS related adverse outcomes.