The Preoperative Supplementation With Vitamin D Attenuated Pain Intensity and Reduced the Level of Pro-inflammatory Markers in Patients After Posterior Lumbar Interbody Fusion

Abstract

The aim of this experimental study was to assess whether 5 weeks of preoperative supplementation with vitamin D affects the intensity of pain and the level of inflammatory markers in patients undergoing posterior lumbar interbody fusion (PLIF) followed by rehabilitation. 42 patients were divided, by double-blind randomization, into two groups: supplemented (SUPL) vitamin D (3200 IU dose of vitamin D/day for 5 weeks) and placebo group (PL) treated with vegetable oil. The 10-week program of early rehabilitation (3 times a week) was initiated 4 weeks following PLIF. Measurements of serum 25(OH)D₃ and CRP, IL-6, TNF-α, and IL-10 were performed. Pain intensity was measured using VAS. After supplementation with vitamin D serum, the concentration of 25(OH)D₃ significantly increased in the SUPL group (^∗ p < 0.005) and was significantly higher as compared to the PL group (^∗ p < 0.001). A significant reduction in pain intensity was observed 4 weeks after surgery and after rehabilitation in both groups. In the SUPL group, serum CRP and IL-6 concentration significantly decreased after rehabilitation, compared with the postsurgical level (^a p < 0.04). The level of TNF-α was significantly lower after rehabilitation only in the supplemented group (^∗ p < 0.02). There were no significant changes in the IL-10 level in both groups during the study. Our data indicate that supplementation with vitamin D may reduce systemic inflammation and when combined with surgery and early postsurgical rehabilitation, it may decrease the intensity of pain in LBP patients undergoing PLIF. Data indicate that LBP patients undergoing spine surgery should use vitamin D perioperatively as a supplement.

Keywords: VAS; early rehabilitation; inflammatory cytokines; low back pain; vitamin D.

FIGURE 1

The timelines of the program.

FIGURE 2

The concentration of vitamin D in serum of LBP patients. Results were expressed as mean ± SEM. SUPL (n = 18), PL (n = 21), ^∗p < 0.001 – difference between the means between indicated groups. ^ap < 0.005 – difference between the indicated results/mean and T1 SUPL. ^bp < 0.05 – difference between the indicated results/mean and T1 SUPL. ^cp < 0.0002 – difference between the indicated results/mean and T2 SUPL. ^Ap < 0.03 – difference between the indicated results/mean and T1 PL.

FIGURE 3

The effect of vitamin D supplementation on VAS. Results were expressed as mean ± SEM, SUPL (n = 18), PL (n = 21); ^ap < 0.006 – difference between the indicated results/mean and T1 SUPL, ^bp < 0.0001 – difference between the indicated results/mean and T1 SUPL, ^dp < 0.002 – difference between the indicated results/mean and T2 SUPL. ^Ap < 0.05 – difference between the indicated results/mean and T1 PL. ^Bp < 0.0001 – difference between the indicated results/mean and T1 PL. ^Dp < 0.001 – difference between the indicated results/mean and T2 PL.

FIGURE 4

The serum CRP (A), IL-6 (B), TNF- α (C), and IL-10 (D) concentrations in LBP patients. Results were expressed as mean ± SEM. SUPL (n = 18), PL (n = 21); ^∗p < 0.05 – difference between the means indicated groups; ^ap ≤ 0.04 – difference between the indicated results/mean and T3 SUPL, ^bp < 0.02 – difference between the indicated results/mean and T1 SUPL.

FIGURE 5

Possible mechanism(s) of vitamin D-dependent pain modulation include its anti-inflammatory effects mediated by the reduced cytokine(s). The sedentary lifestyle, obesity, elevated inflammation as well as paraspinal muscle atrophy and mitochondrial dysfunction (Dzik et al., 2018) reversely, are associated with vitamin D deficiency/insufficiency. We assume that above-listed factors intensify the pain in LBP patients. Preoperative vitamin D supplementation is accompanied by normalized serum vitamin D concentration, inhibition of muscle atrophy and restoration of mitochondrial function. After supplementation with vitamin D, the reduction of inflammation and alleviation of pain is observed in LBP patients after PLIF surgery followed by early rehabilitation. Taken together, our study support anti-inflammatory and pain-relieving actions of vitamin D that may promote the recovery process. ↓ – decrease of factor, ↑ – increase of factor, ⊣ – inhibition, blue arrows – negative interaction, green arrow – positive interaction/protocol time.