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Dyskopatia lędźwiowa


Nowe wytyczne leczenia operacyjnego zespołów bólowych kręgosłupa lędźwiowo-krzyżowego.

New Guideline For Low-Back Pain Interventions, Surgery Issued By The American Pain Society 

The American Pain Society (APS) has issued a new clinical practice guideline for low back pain that emphasizes the use of noninvasive treatments over interventional procedures, as well as shared decision making between provider and patient. The findings are published in the current (May 1, 2009) issue of the journal Spine.

The new APS guideline, based on an extensive review of existing research, provides clinicians with eight recommendations to help determine the best way to treat patients with low-back pain. It also expands its current and previously published guideline for initial evaluation and management of this chronic condition.
"These recommendations are based on an even more complete body of evidence than was available just a few years ago. Consequently, we believe these recommendations will give physicians more confidence when treating patients with persistent back pain," said Roger Chou, M.D., lead author, director of the APS Clinical Practice Guideline Program, and associate professor of medicine (general internal medicine), Oregon Evidence-based Practice Center, Oregon Health & Science University.
"Unfortunately, randomized trials for a number of commonly used interventional procedures are still too limited to generate evidence-based recommendations, and our review also highlights the need for more research," Chou added.
Low-back pain is the fifth most common reason for doctor's visits and accounts for more than $26 billion in direct health care costs nationwide each year. While a number of interventional diagnostic tests and therapies, and surgery are available, and their use is increasing, in some cases their usefulness remains uncertain.
"We have advocated strongly in many of our recommendations for physicians to use shared decision making because of the relatively close trade-offs between potential benefits relative to harms, as well as costs and burdens of these various treatment options," Chou explained. Shared decision making involves a patient's full participation in medical choices after receiving comprehensive information about the impact of all options on his or her particular life situation.

To develop the guideline, a multidisciplinary APS panel, augmented by experts on interventional therapies, reviewed 3,348 abstracts and analyzed 161 relevant clinical trials. The panel found that the evidence for the use of these interventions was mixed, sparse or not available. Based on the data the panel gathered, the APS now recommends:

  1. Against the use of provocative discography (injection of fluid into the disc in order to determine if it is the source of back pain) for patients with chronic nonradicular low-back pain. 
  2. The consideration of intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis for patients with nonradicular low-back pain who do not respond to usual, non-interdisciplinary therapies.
  3. Against facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injections for patients with persistent nonradicular low-back pain, and insufficient evidence to guide use of other interventional therapies.
  4. A discussion of risks and benefits of surgery and the use of shared decision making with reference to rehabilitation as a similarly effective option for patients with nonradicular low-back pain, common degenerative spinal changes, and persistent and disabling symptoms.
  5. Insufficient evidence to guide recommendations for vertebral disc replacement.
  6. A discussion of the risks and benefits of epidural steroid injections and shared decision making, including specific review of evidence of lack of long-term benefit for patients with persistent radiculopathy due to herniated lumbar disc.
  7. A discussion of the risks and benefits of surgery and use of shared decision making that references moderate benefits that decrease over time for patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain.
  8. Discussion of risks and benefits of spinal cord stimulation and shared decision making, including reference to the high rate of complications following stimulator placement for patients with persistent and disabling radicular pain following surgery for herniated disc and no evidence of a persistently compressed nerve root.

Chou and his colleagues also reaffirm their previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. "In general, noninvasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery," said Chou.
Recommendations from the first APS Clinical Practice Guideline on Low-Back Pain are intended for primary care physicians and appeared in the Oct, 2, 2007, issue of the Annals of Internal Medicine. For diagnosis, the first APS low-back pain guideline advises clinicians to minimize routine use of X-rays or other diagnostic tests except for patients known or believed to have underlying neurological or spinal disorders.

Source: Tamara Hargens-Bradley, Oregon Health & Science University


  

 

Zabiegi endoskopowe w dyskopatii lędźwiowej maja gorsze wyniki.

Newer, Minimally Invasive Surgical Procedure For Treatment Of Sciatica Does Not Result In Better Outcomes

A comparison of surgical treatments for sciatica finds that the minimally invasive procedure known as tubular diskectomy does not provide a significant difference in improvement of functional disability compared to the more common surgery, conventional microdiskectomy, according to a study in the July 8 issue of JAMA.

Sciatica or lumbosacral radicular syndrome affects millions of individuals worldwide and is typically caused by disk herniation. Surgery is offered to patients with persistent pain that is not responding to conservative treatment, with the common surgical procedure being microdiskectomy (removal of injured disk tissue and pieces). The minimally invasive technique of transmuscular tubular diskectomy was introduced in 1997. "The rationale behind replacing the conventional subperiosteal muscle dissection by the muscle-splitting transmuscular approach of tubular diskectomy is less tissue damage, resulting in a faster rate of recovery but with similar long-term outcomes. Patients are expected to have reduced postoperative back pain, thus allowing quicker mobilization and contributing to shorter hospitalization and faster resumption of work and daily activities," the authors write. Although this procedure was introduced to increase the rate of recovery, there is a lack of evidence, according to background information in the article.

Mark P. Arts, M.D., of the Medical Center Haaglanden, the Hague, the Netherlands, and colleagues conducted a multicenter trial to determine the outcomes and time to recovery in patients with lumbar disk herniation treated with tubular diskectomy or conventional microdiskectomy. The study included 328 patients age 18 to 70 years who had persistent leg pain (greater than 8 weeks) due to lumbar disk herniations. Patients were randomized to either tubular diskectomy (n = 167) or conventional microdiskectomy (n = 161). Functional ability, pain and self-report of recovery were measured via a questionnaire or surveys.

The researchers found: "The expected treatment benefit of a faster rate of recovery from sciatica after tubular diskectomy could not be reproduced by this double-blind study. This study revealed evidence that the rates of recovery for the minimally invasive tubular diskectomy and conventional microdiskectomy were similar. In contrast, the overall differences in pain intensity and recovery rates favored the conventional microdiskectomy approach."

At 1 year, 107 of 156 patients (69 percent) assigned to tubular diskectomy reported a good recovery vs. 120 of 151 patients (79 percent) assigned to conventional microdiskectomy.

"Although the minimally invasive technique of tubular diskectomy seemed to be an attractive surgical method for treating sciatica, our data do not support a higher rate of recovery when compared with conventional microdiskectomy. On the contrary, patients who underwent tubular diskectomy fared worse with regard to leg and back pain and fewer patients reported complete recovery at 1 year," the authors conclude.


Źródło: Journal of the American Medical Association, JAMA. 2009;302[2]:149-158.