The low back pain population includes a wide variety of patients (Walker, 2000). Not all patients should go through such diagnostic processes and treatments. 90% of acute back pain patients will resolve spontaneously in the first three months and among the reminders not all will suffer enough to necessitate such approaches. For the small portion of the patients needing invasive therapies, non reversible procedures should take place only when a valid diagnostic strategy has been undertaken. In chronic back pain patients, surgery is never an emergency.
The principal problems leading to FBSS can be classified in 4 categories.
Knowledge update: All physicians taking care of low back pain patients should be aware of the leading epidemiological causes of acute and chronic back pain, of the headlines of the diagnostic algorithm in chronic back pain and detect the biological and psychological red flags.
Common sense evidence: Relying on history, physical examination and non MRI radiological findings may lead to wrong diagnostic, false security and sometimes to the wrong operation. Common sense is needed to treat low back pain but some historical evidences should be reconsidered.
Diagnosis process: Shortcuts from radiological findings to spinal surgery are not acceptable for chronic low back pain patients. Unless the source of pain can be determined precisely and that source possesses at least a mechanical component, surgery has no role.
Surgery is not the ultimate solution: The surgical approach must be confronted to a recent RCT comparing lumbar instrumented fusion with cognitive intervention and exercise in patients with chronic low back pain due to disk degeneration. This study was unable to detect any difference after one year in pain, analgesic consumption, satisfaction and return to work rate (Brox et al., 2003). Moreover, when evaluating surgical results, it is important to consider radiographic fusion and functional outcome separately, thus improvement rate following surgery remains non conclusive. A comprehensive review suggests that 68% of patients have a satisfactory outcome following lumbar fusion; however, long term follow-up of decom-pressive laminectomy for lumbar spinal stenosis has shown no difference in outcome between surgical and non-surgical treatments (Turner et al., 1992) (Iguchi et al., 2000).
An 18 year follow-up in patients with spondylolisthesis showed that surgical interventions are indicated only for radiculopathies (Matsunaga et al., 2000).
Collaboration related: Interdisciplinary approach is essential to investigate patients before surgery and to insure an adequate follow-up after. On the biological point of view, if surgery is performed only after a proper algorithm is followed, the target related procedure has the place it deserves; the adequate treatment.
We do not think the strategy described above will reduce the number of surgical procedures, but hopefully it may lead to more precise diagnosis and this will allow a better patient selection.
The trend is now for less invasive techniques and the industry have redirected their efforts towards the development of minimally invasive approaches. This economical and technological input will give birth to new high tech instruments. New ideas arise from our daily practice and a critical and constructive spirit will contribute to reduce the morbidity linked to our still incomplete understanding of pain and disability.
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