Abstract

ROBAINA-PADRON, F.J.. Controversies of instrumented surgery and pain relief in degenerative lumbar spine: Results of scientific evidence. Neurocirugía [online]. 2007, vol.18, n.5, pp.406-413. ISSN 1130-1473.

Investigation and development of new techniques for intrumented surgery of the spine is not free of conflicts of interest. The influence of financial forces in the development of new technologies an its imediately application to spine surgery, shows the relationship between the published results and the industry support. Even authors who have defend eagerly fusion techniques, it have been demostrated that them are very much involved in the revisión of new articles to be published and in the approval process of new spinal tecnologies. When we analize the published results of spine surgery, we must bear in mind what have been call in the "American Stock and Excahnge" as "the bubble of spine surgery". The scientific literature doesn't 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 necessary 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". Nonetheless, 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 the spinal fusions in the degenerative disc disease, discogenic pain and inespecific back pain. After decades of advances in this field, the results of spinal fusions are mediocre. New 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 sligtly 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 placebo effect, or the conservative treatment. The European Guidelines for lumbar chronic pain management show 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 sending a message to use "minimally invasive techniques", abandon transpedicular fusions and clearly indicating that we must apply the knowledge accumulated at least along the last 20 years based on the scientific evidence. In conclussion, based in recent information, we must recomend the "abandon of the instrumented pathway" in a great number of present indications for degenerative spine surgery, and look for new strategies in the field of rehabilitation and conservative treatments correctly apply, using before the decompressive and instrumented surgery all the interventional and minimally invasive techniques that are presently offer in the field of modem lumbar chronic pain treatment.

Keywords : Chronic low back pain; Degenerative lumbar disease; Spinal instrumentation; Evidence based medicine.

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