Intervention Review ArticleA brief overview of evidence-informed management of chronic low back pain with surgery
Introduction
Over the last few years, billions of dollars have been spent worldwide on surgery for people with chronic low back pain (CLBP), and thousands of research articles have been dedicated to the subject. Despite numerous technological advances in surgical procedures and devices, there are still no clearly defined clinical practice guidelines related to surgical intervention of CLBP in the absence of serious structural disease such as instability, infection, or neoplasm.
Low back pain (LBP) is extremely common, with point prevalence as high as 33% [1] and 6-month prevalence as high as 73% [2]. Most cases of LBP are self-limiting, with no persistent or serious sequelae. Even among those with LBP and comorbidities associated with the development of disability, less than 10% experienced loss of work longer than 1 week over a 5-year period [3]. For the small percentage of patients with incapacitating CLBP, the question remains as to why are they so severely affected when others with similar degenerative findings can be asymptomatic. This is perhaps not surprising given that the cause of CLBP in the absence of serious spinal disease is poorly understood. Therefore, any decision regarding the appropriate use of surgery for CLBP must be made not only with regard to the presumed structural cause of pain, but also by considering the psychosocial and economic context of the patient. Disabling CLBP develops more frequently in patients who, at the initial evaluation, have a high level of “fear avoidance” (an exaggerated fear of pain leading to avoidance of beneficial activities), psychological distress, disputed compensation claims, involvement in a tort-compensation system, or job dissatisfaction [3], [4], [5], [6], [7].
Section snippets
History
Despite the tenuous link between degenerative disc disease (DDD) and CLBP, the disc has been the focus of a large majority of information and research regarding the etiology of LBP since it was recognized as a distinct entity in the last century. Surgery for disc herniation was first performed by Oppenheim and Kruse in 1909, and Holdsworth and Hardy were the first to report on internal fixation of the spine in patients with fracture dislocations of the thoracolumbar spine in 1953 [8]. Boucher
Indications
Because physical examination and detailed imaging techniques have failed to delineate a clear pathoanatomic cause for patients with CLBP, it is difficult to identify those individuals who would benefit from surgical intervention, and the type of intervention that is most suitable to a particular patient. Not surprisingly, this lack of consensus had lead to huge geographical variations in use of surgery for LBP across the United States [31]. In addition to uncertainty regarding the efficacy of
Contraindications
Many contraindications to surgery are nonspecific and include general medical considerations of cardiac, pulmonary, and metabolic reserves, prohibitive anesthetic risk, and patients unable to comprehend the intentions and limitations of surgery. Although there is no absolute contraindication specifically related to the spine, there are certainly factors that have been shown to predict a poor outcome to surgical intervention for CLBP. Patients with high fear avoidance of pain, psychological
Surgical treatment for lumbar degenerative disc disease
After the success of laminectomy and discectomy in treating patients with sciatica secondary to herniation, the same technique was applied to CLBP associated with DDD. Anecdotal reports of early success with this procedure were far outweighed by subsequent reports of failures, which were much more common. For DDD without neurological symptoms, the practice of laminectomy has largely been abandoned [35]. There are four general categories of procedures currently used for the surgical treatment of
Mechanism of action
Because the elimination of motion after solid arthrodesis has been effective for pain relief in other arthritic joints within the body (eg, ankle, wrist, hip) it is no surprise that surgical fusion to eliminate motion has been used to treat CLBP. However, the complexity of the multiple spinal articulations and uncertainty in determining whether these joints are in fact responsible for generating CLBP have brought this practice into question. Some authors have observed a lack of correlation
Mechanism of action
The premise for disc arthroplasty stems from the assumption that the pain in CLBP stems from an abnormal and painful spinal motion segment, and that the artificial disc would function as a painless and physiologic replacement for the degenerated disc. This premise is buoyed by the success in treating arthritic hips and knees with arthroplasty, where replacements are now expected to last 15 to 20 years in an elderly population. Proponents of disc arthroplasty often argue that this approach is
Dynamic stabilization
There are four main types of dynamic stabilization devices: 1) dynamic interspinous spacers; 2) static interspinous spacers; 3) pedicle screw-/rod-based posterior dynamic stabilizing systems (PDS); and 4) total facet replacement systems (Table 2) [60], [61].
Summary
The use of surgery for CLBP in the absence of serious structural disease is a complex issue in which decisions about the type of procedure used should be secondary to evaluating the underlying cause of pain and establishing that a particular individual is in fact an appropriate surgical candidate. Although there are multiple surgical options for the treatment of CLBP, there is currently insufficient evidence on which to draw any firm conclusions as to their effectiveness on clinical outcomes.
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2014, Revista Medica Clinica Las CondesTissue engineering strategies applied in the regeneration of the human intervertebral disk
2013, Biotechnology AdvancesCitation Excerpt :Additionally, it has been demonstrated that the disk implant does not have elastic shock absorption properties and could eventually produce abnormal forces along the facet joints and dimensional changes of the intervertebral foraminal during motion (Bono and Garfin, 2004). Dynamic stabilization makes use of spacers that will augment the interspinous space and unload the disk and facet joints, thus reducing compression of the nerves (Don and Carragee, 2008). This procedure is indicated in the treatment of LBP caused by spinal stenosis and facet joint arthrosis, although there is no convincing evidence supporting the use of this technique.
The impact of discography on the surgical decision in patients with chronic low back pain
2012, Spine JournalCitation Excerpt :It is well documented that conservative treatment may reduce pain, improve the ability to cope with the remaining pain, and restore working capacity [9,10]. When conservative treatment is unsuccessful, surgery might be considered [10–12]. Patients with DDD are usually asymptomatic or minimally symptomatic, but if suffering from CLBP frequently presents a history of low back pain that varies with different body positions, movements, and loads, indications that a mechanical issue is the cause of the pain.
FDA device/drug status: approved for these indications (Total disc replacement and IDET); approved but not for this indication (Posterior dynamic Stabilizers/Interspinous Devices).
Nothing of value received from a commercial entity related to this manuscript.