Operative Therapiemaßnahmen bei chronischem Rückenschmerz - Nutzen und Stellenwert operativer Verfahren

Die meisten Patienten mit chronischen Rückenschmerzen sollten initial konservativ therapiert werden, wobei ein multimodaler Ansatz empfehlenswert ist. Neben medikamentösen und physikalischen Maßnahmen zählt dazu eine umfassende Information der Patienten, wie auch eine Förderung ihrer Aktivität und Eigeninitiative. Bei Hinweisen auf die Bedeutung biopsychosozialer Faktoren ist eine entsprechende Anpassung der Behandlung erforderlich. Patienten, bei denen trotz solcher Therapiemaßnahmen über einen ausreichend langen Zeitraum keine Besserung zu erzielen ist, sollten über operative Maßnahmen, mögliche Risiken und die zu erwartende Prognose informiert werden.

The initial treatment of most patients with chronic low back pain should consist of non-operative therapy, preferably according to established multimodal protocols. Part of that therapy should be sufficient pain management and physical therapy as well as information of the patients about the nature of their disease and the role of cognitive-behavioral factors. In case of patients with anticipated psychosocial co-morbidity modification of the therapy is required. However, if conservative therapy fails despite adequate duration, one should consider surgery and inform patients about its effectiveness and potential complications.

Key words

chronic low back pain (LBP) - operative treatment - non-operative therapy - outcome prediction - complications

Literatur

• 1 Airaksinen O, Brox JI, Cedraschi C. et al. . European guidelines for the management of chronic nonspecific low back pain.  Eur Spine J. 2006;  15
• 2 Atlas SJ, Delitto A.. Spinal stenosis: surgical versus nonsurgical treatment.  Clin Orthop Relat Res. 2006;  443 198-207
• 3 Atlas SJ, Keller RB, Wu YA. et al. . Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study.  Spine. 2005;  30 927-935
• 4 Awad JN, Moskovich R.. Lumbar disc herniations: surgical versus nonsurgical treatment.  Clin Orthop Relat Res. 2006;  443 183-197
• 5 Brox JI, Sorensen R, Friis A. et al. . Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration.  Spine. 2003;  28 1913-1921
• 6 Carragee E.. Surgical treatment of lumbar disk disorders.  JAMA. 2006;  296 2485-2487
• 7 den Boer JJ, Oostendorp RA, Beems T. et al. . Continued disability and pain after lumbar disc surgery: the role of cognitive-behavioral factors.  Pain<. 2006;  123 45-52
• 8 den Boer JJ, Oostendorp RA, Beems T. et al. . A systematic review of bio-psychosocial risk factors for an unfavourable outcome after lumbar disc surgery.  Eur Spine. 2006;  15 527-536
• 9 Dreinhöfer KE, Merx H, Puhl W.. GBE-Schwerpunktbericht: Muskuloskelettale Erkrankungen. In: Robert Koch-Institut, ed. Gesundheitsberichterstattung des Bundes. Berlin (im Druck) 2008
• 10 Fairbank J, Frost H, Wilson-MacDonald J. et al. . Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial.  BMJ. 2005;  330
• 11 Fritzell P, Hagg O, Wessberg P, Nordwall A.. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.  Spine. 2006;  26 2532-2534
• 12 Gibson JN, Waddell G.. Surgery for degenerative lumbar spondylosis: updated Cochrane Review.  Spine. 2005;  30 2312-2320
• 13 Hagg O, Fritzell P, Ekselius L, Nordwall A.. Predictors of outcome in fusion surgery for chronic low back pain. A report from the Swedish Lumbar Spine Study.  Eur Spine J. 2003;  12 22-33
• 14 Jansson KA, Nemeth G, Granath F, Blomqvist P.. Surgery for herniation of a lumbar disc in Sweden between 1987 and 1999. An analysis of 27,576 operations.  J Bone Joint Surg Br. 2006;  86 841-847
• 15 Jansson KA, Nemeth G, Granath F, Blomqvist P.. Spinal stenosis re-operation rate in Sweden is 11 % at 10 years - a national analysis of 9,664 operations.  Eur Spine J. 2005;  14 659-663
• 16 Malmivaara A, Slatis P, Heliovaara M. et al. . Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial.  Spine. 2007;  32 1-8
• 17 Moller H, Hedlund R.. Instrumented and noninstrumented posterolateral fusion in adult spondylolisthesis - a prospective randomized study: part 2.  Spine. 2000;  25 1716-1721
• 18 Moller H, Hedlund R.. Surgery versus conservative management in adult isthmic spondylolisthesis - a prospective randomized study: part 1.  Spine. 2000;  25 1711-1715
• 19 Ng LC, Sell P.. Predictive value of the duration of sciatica for lumbar discectomy. A prospective cohort study.  J Bone Joint Surg Br. 2004;  86 546-549
• 20 Rampersaud YR, Moro ER, Neary MA. et al. . Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols.  Spine. 2006;  31 1503-1510
• 21 Vibert BT, Sliva CD, Herkowitz HN.. Treatment of instability and spondylolisthesis: surgical versus nonsurgical treatment.  Clin Orthop Relat Res. 2006;  443 222-227
• 22 Weinstein JN, Lurie JD, Tosteson TD. et al. . Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort.  JAMA. 2006;  296 2451-2459
• 23 Weinstein JN, Tosteson TD, Lurie JD. et al. . Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial.  JAMA. 2006;  296 2441-2450

1 1 Spinal Patient Outcomes Research Trial

Korrespondenz