Columna

07. REVISIONES.qxd

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Página 167

REVISIONES

167

Rev. Soc. Esp. Dolor
3: 167-172; 2006

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.
F. J. Robaina 1
R obaina F. J.
Present state of degenerative backsurgery
and its implications in the management of
chronic lumbar pain, canal stenosis and
degenerative disk disease. Evidence based
outcomes.

SUMMARY
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 followingthe
“ 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 herniated lumbar disc. For that reason , we are still triying to
find new treatment options in the nonsurgical field of herniated lumbar disc. When we analize the published results of
the spine surgery, we must beardin 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

Jefe de laUnidad del Dolor Crónico y Neurocirugía
Funcional
Hospital Universitario de Gran Canaria Dr. Negrín
1

Recibido: 21/12/05
Aceptado: 15/01/06

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 becausepatients 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 nonproved 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 studiesin 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 asimple, 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 themodern 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 interventional techniques that are presently offer in the field of modern
chronic...