The general opinion of back specialists today regarding surgery
stresses that such invasive treatment should only be the last
resort of all possible measures.
Unfortunately still for various reasons many doctors, who have
been brought up in the last 50 years in the therapeutic approach
of "Western medicine", are inclined to respond all to
quickly to the demands of back patients with pharmaceutical or
mechanical cures for their ailments.
In the last five years, a more critical and pragmatic evaluation
of all current treatment with regard to long term follow-up surveys
of spine patients is changing the priorities in diagnostics and
therapy. Furthermore, economical constraints have also necessitated
a re-evaluation of the treatment approach.
Today, third-party payers are looking for objective, measurable
and long-lasting results and are turning their backs on more traditional
methods.
Professor R.P. Graebe MBChB, M. Med.(Chir Orth), Dept. of Orthopaedic
Surgery, University of Pretoria, RSA, recently published a comprehensive
report about current views and his professional life-long experience
regarding treatment of Lumbosacral Backache.
His list of statements by leading spine specialists reads as
follows:
Up to 98% of all acute backaches resolve without specific treatment.
The success rate of non-operative treatment of secured lumbar
disc herniation is as high as 90% in 3 months. In most cases of
scan proven herniated discs a control ~12 months later showed
a decrease in size by an average 75%. The problem is resolved
thanks to the natural healing mechanisms of the body.
Reports about the success rate of spinal surgery confirm that
up to 50% of all operated patients were still suffering from neck
and back pain, needing medication. Main reason: The preoperative
difficulty in pinpointing the exact location and cause of back
pain. A specific diagnosis in "acute low backache" is
only possible in up to 20% of patients, and in "chronic backache"
in only 50%. Regarding the accuracy of MRI, we should consider
that 30% of the population have signs of pathological spine alterations
but are absolutely symptom- and pain-free. More relevant are Electromyography
(EMG) and the Analysis of fibrinolytic activity in the cerebrospinal
fluid (Volvo-Study) for detecting nerve root irritation and nerve
compression. X-ray signs of a degenerated intervertebral disc
are not always a sign of instability and a cause of pain. But
the degree of pain and altered blood- circulation can well be
visualised by special infrared/ thermography testing devices.
The famous late physician Homer Pheasant, a founder member of
the International Society for Study of the Lumbar Spine, said:
"It is because of the tendency to turn sour, as much as to
the success of non-operative measures that the more experienced
spinal surgeon graduates to the status of a spinal physician".
However, if surgery is applied to the right patient with correct
indications, excellent results can be expected.
SURGERY METHODS:
Discectomy: This operation is performed in only a few cases
of disc prolapse, when the protrusion does not return to its original
position and is causing nerve root compression. Keep in mind –
this is a common misunderstanding, may e because of the terminus
‘Discectomy’ - most of the disc is left in place. Only
the protruding piece of cartilage is removed.
Decompression: The SPINAL CANAL is too narrow at one spot,
called Central or Lateral Canal Stenosis: A widening by surgery
may be necessary to relieve pressure on nerves. First type of
decompression operation: Laminectomy, i.e. a small piece of bone
is removed from the lamina (part of the vertebra). Second type
of decompression operation: Facetectomy, i.e. part of the inner
edge of the facet joint is removed.
Spinal Fusion: Indicated in some cases of severe lumbar
instability. Excessive movements of any part of the spine can
cause back pain or intermittent sciatica. An advanced instability
of a facet joint leading to repeated spine disalignment or the
so-called Spondylolisthesis, when a vertebra slips ‘out of
line’, are indications for a Spinal Fusion. Most surgeons
are reluctant to perform this operation unless all other therapeutic
measures were unsuccessful. Main reason: The blocking of movement
in one segment requires more movement of the adjacent segments.
The next operation in most cases unfortunately has to be booked
within a short period.
With respect to spine treatment in the near future, the strategy
of health care providers and of the insurance industry will change,
aiming at a drastic reduction of treatment- and disability- costs.
Programmes using motion and loading as treatment in gym-like Back
Clinics - ACTIVE SPINE RESTORATION - are gaining popularity. The
functional capacity of the spine has to be enhanced based on a
computerised, exact evaluation of mobility, strength and endurance
of the spine. Those who visit and train in Back Schools should
be rewarded by a special premium by Insurance Companies. Also
those investing in Ergonomic Seating and Workstations based on
ergo consultancy and analysis of Occupational Health Specialists
should have special and advantageous conditions with Medical Aid
Schemes. Governments and Unions will be challenged for those changes
in the work
environment.
