Situación actual de la cirugía de la columna vertebral degenerativa aplicada al manejo del dolor lumbar crónico: Estenosis de canal. Discopatia degenerativa, resultados basados en la evidencia científica

摘要

The finding of therapeutical solutions for patines suffering of chronic low back pain and failed back syndrome is one of the main work load that Chronic Pain Units have to manage every day. The results displayed in publications done following the "principles of evidence based medicine", shows that still there is not any correctly done study that compares the conservative and surgical treatments in the manegement of her-niated lumbar disc. For that reason , we are still triying to find new treatment options in the nonsurgical field of her-niated lumbar disc. When we analize the published results of the spine surgery, we must beard in mind what have been call in the "American Stock and Excahnge" "the bubble of spine surgery". The scientific literature does not show clear evidence in the cost-benefict studies of most instrumented surgical interventions of the spine compare with the conservative treatments. It has not been yet demostrated that fusion surgery and disc replacement are better options than the conservtive treatment. It′s necesary to point out that at present "there are relationships between the industry and back pain and there is also an industry of the back pain" . Nontheless, the "market of the spine surgery" is growing up because patients are demanding solutions for their back problems. The tide of scientific evidence seams to go against of the spinal fusions in the degenerative disc disease, discogenic pain and inespecific back pain. After decades of technological advances in this field, the results of spinal fusions are mediocre. Recent epidemiological studies show that "spinal fusion must be accepted as a non proved or experimental method for the treatment of back pain". The surgical literature on spinal fusion published in the last 20 years following the Cochrane?s method stablish that: 1- this is at least incomplete, not realiable and careless; 2- the instrumentation seems to sligthy increase the fusion rate ; 3- the instrumentation doesn?t improve the clinical results in general, lacking studies in subgroups of patients. We still are needing randomized studies to compare the surgical results with the natural history of the disease, the pacebo effect, or the conservative treatment. The European Guidelines for lumbar chronic pain management shows a strong evidence indicating that complex and demanding spine surgery where different instrumentation is used, is not more effective than a simple, safer and cheaper posterolateral fusion without instrumentation. Recently, the literature published in this field, is showing us a tendency to use again "minimally invasive techniques", abandon transpedicular fusions, and indicating clearly that we must apply the knowledge based on the scientific evidence accumulated at least along the last 20 years. In conclussion, based in the modern information, we must recomend the abandon of the instrumented pathway in a great number of present indications for spine surgery, and look for new management strategies in the field of rehabilitation and conservative treatments correctly apply, using before the decompresive and instrumented surgery all the intervention-al techniques that are presently offer in the field of modern chronic pain treatment.