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Review Article | DOI: https://doi.org/
*Corresponding Author:
Citation:
Copyright: © Seyed amir 2018 et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 30 November -0001 | Accepted: 25 June 2018 | Published: 06 August 2018
Keywords: Low back pain, Spinal fusion, Minimally invasive surgical procedures, Pedicle screws, Zygapophyseal joints, Intervertebral disc degeneration.
Low back pain (LBP) is a worldwide phenomenon. The UK studies place LBP as the largest single cause of absence from work; up to 80% of the population will experience LBP at least once in their lifetime. Most individuals do not seek medical care and are not disabled by their pain once it is managed by nonoperative measures. However, around 10% of patients go on to develop chronic pain. This review outlines the basics of the traditional approach to spinal surgery for chronic LBP secondary to osteoarthritis of the lumbar spine as well as explains the novel concepts and terminology of back pain surgery.
Three randomized controlled trials of fusion for low back pain and two controlled trials of disc arthroplasty have been published in recent years. These studies provide data that allow an appraisal of how effective surgery is for the treatment of chronic low back pain.
The study of Fritzell and colleagues [1] showed that fusion was more effective than conservative care. The study of Brox and colleagues [2] found fusion to be no more effective than cognitive therapy and exercises. The study of Fairbank and colleagues [3] found fusion to be minimally more effective than a rehabilitation program. Improvements in Oswestry Disability Index (ODI) were from 47.3 to 35.7 in the Fritzell study, from 42 to 26 in the Brox study, and from 46.5 to 34 in the Fairbank study.
As pointed out by Mirza and Deyo [4], the mean improvements in ODI achieved in two of these studies [1,3] were less than the threshold of 15 points that the US Food and Drug Administration considers to be the minimal clinically important change (MCIC). The Brox study exceeded this threshold by 0.6 points. In the Fritzell study, only 29% of patients rated themselves as ‘much better’. No patient was reported as having been rendered free of pain. The other two studies did not report this outcome. The Fairbank study reported a change in mean scores for bodily pain from 28.6 to 48.1. In the Brox study, pain scores improved by 20 points (from 60 to 40), which barely equals the MCIC for back pain.
Blumenthal et al. [5] compared disc arthroplasty, using a particular device, with a form of anterior lumbar interbody fusion. Zigler et al. [6] compared arthroplasty, using a different device, with circumferential fusion. Although the Blumenthal study found disc arthroplasty to be not inferior to fusion, the outcomes of arthroplasty were modest. Mean pain scores improved by 40 points (from 70 to 30), which exceeds the MCIC of 20 points, and ODI improved from 50 to 25. But 64% of patients treated by surgery still took opioids, and although 64% returned to work, 53% had been working before surgery. These latter figures do not attest to any decrease in the burden of illness; surgery did not seem to alter the patients' use of other health care services, or their ability to work.
SPINE PATIENT OUTCOMES RESEARCH TRIAL I, II, III (STUDY DESIGN)
In total, the SPORT studies included approximately 2500 patients, with over 1000 randomized, from 13 sites across the country to investigate the clinical efficacy of surgery as treatment for the three common causes of lower back pain and neurogenic claudication, including lumbar disc herniation, DS, and spinal stenosis. An independent RCT was carried out for each of these three disorders. Eligibility criteria were based on evidence-based management algorithms developed by the Agency for Health Care Policy and Research and others. In brief, progression or persistence of incapacitating back pain or neurogenic claudication after a 6–12 week period of nonoperative care was required prior to trial enrollment. Preenrollment nonoperative care included counseling, physical therapy, epidural injections, chiropractic therapy, and opioid analgesics.[12,13,17] Exclusion criteria included prior surgery, cauda equina syndrome, segmental instability (more than 4 mm or 10° of angular motion between flexion and extension), and spine fractures, infections, tumors, or inflammatory spondyloarthropathy. Eligible patients were randomly assigned to surgical treatment or continued nonoperative treatment at the time of enrollment.
SPINE PATIENT OUTCOMES RESEARCH TRIAL I: LUMBAR DISC HERNIATION
This RCT randomized 501 surgical candidates (245 assigned to surgery, 256 assigned to nonoperative management) with imaging-confirmed lumbar intervertebral disc herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks. Patients were randomized to standard open discectomy or nonoperative care as described in the above study design section. Despite the randomized-control study design, adherence to assigned treatment was poor. Within 3 months of enrollment, only 50% of patients assigned to receive surgery underwent surgery, whereas 30% of those assigned to receive nonoperative treatment underwent surgery.
SPINE PATIENT OUTCOMES RESEARCH TRIAL II: DEGENERATIVE SPONDYLOLISTHESIS
This multicenter RCT investigated the efficacy of surgery as treatment for spondylolisthesis with spinal stenosis.[12] Surgical candidates with at least 12 weeks of symptoms (back pain, neurogenic claudication, or radicular leg pain with associated neurologic pain) and image-confirmed DS were enrolled in a randomized cohort (304 patients; 159 surgical, 145 nonsurgical) or an observational cohort (303 patients; 173 surgical, 130 nonsurgical).[12] Treatment consisted of standard decompressive laminectomy (with or without fusion) or nonoperative care as described in the above study design section. As was observed with SPORT I, the 1-year crossover rates were high in the randomized cohort (approximately 40% in each direction).
SPINE PATIENT OUTCOMES RESEARCH TRIALS III: SPINAL STENOSIS
This multicenter RCT investigated the efficacy of surgery as treatment for spinal stenosis.[17] Surgical candidates with at least 12 weeks of symptoms (back pain, neurogenic claudication, or radicular leg pain with associated neurologic pain) and imaging findings of spinal stenosis without spondylolisthesis were enrolled in a randomized cohort (289 patients; 138 surgical, 151 nonsurgical) or an observational cohort (365 patients; 219 surgical, 146 nonsurgical). Treatment consisted of standard decompressive laminectomy or nonoperative care as described in the above study design section. As was observed with SPORT I and II, the 1-year crossover rates were high in the randomized cohort (at 1 year, only 63% of patients assigned to the surgical group had undergone surgery whereas 42% assigned to the nonsurgical group underwent surgery).
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