RESUMEN
We randomised a total of 94 patients with long-standing moderate lumbar spinal stenosis (LSS) into a surgical group and a non-operative group, with 50 and 44 patients, respectively. The operative treatment comprised undercutting laminectomy of stenotic segments, augmented with transpedicular-instrumented fusion in suspected lumbar instability. The primary outcome was the Oswestry disability index (ODI), and the other main outcomes included assessments of leg and back pain and self-reported walking ability, all based on questionnaire data from 85 patients at the 6-year follow-up. At the 6-year follow-up, the mean difference in ODI in favour of surgery was 9.5 (95% confidence interval 0.9-18.1, P-value for global difference 0.006), whereas the intensity of leg or back pain did not differ between the two treatment groups any longer. Walking ability did not differ between the treatment groups at any time. Decompressive surgery of LSS provided modest but consistent improvement in functional ability, surpassing that obtained after non-operative measures.
Asunto(s)
Neuralgia/cirugía , Recuperación de la Función , Fusión Vertebral , Estenosis Espinal/cirugía , Descompresión Quirúrgica , Femenino , Humanos , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Neuralgia/etiología , Índice de Severidad de la Enfermedad , Estenosis Espinal/complicaciones , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
STUDY DESIGN: A randomized controlled trial. OBJECTIVES: To assess the effectiveness of decompressive surgery as compared with nonoperative measures in the treatment of patients with lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: No previous randomized trial has assessed the effectiveness of surgery in comparison with conservative treatment for spinal stenosis. METHODS: Four university hospitals agreed on the classification of the disease, inclusion and exclusion criteria, radiographic routines, surgical principles, nonoperative treatment options, and follow-up protocols. A total of 94 patients were randomized into a surgical or nonoperative treatment group: 50 and 44 patients, respectively. Surgery comprised undercutting laminectomy of the stenotic segments in 10 patients augmented with transpedicular fusion. The primary outcome was based on assessment of functional disability using the Oswestry Disability Index (scale, 0-100). Data on the intensity of leg and back pain (scales, 0-10), as well as self-reported and measured walking ability were compiled at randomization and at follow-up examinations at 6, 12, and 24 months. RESULTS: Both treatment groups showed improvement during follow-up. At 1 year, the mean difference in favor of surgery was 11.3 in disability (95% confidence interval [CI], 4.3-18.4), 1.7 in leg pain (95% CI, 0.4-3.0), and 2.3(95% CI, 1.1-3.6) in back pain. At the 2-year follow-up, the mean differences were slightly less: 7.8 in disability (95% CI, 0.8-14.9) 1.5 in leg pain (95% CI, 0.3-2.8), and 2.1 in back pain (95% CI, 1.0-3.3). Walking ability, either reported or measured, did not differ between the two treatment groups. CONCLUSIONS: Although patients improved over the 2-year follow-up regardless of initial treatment, those undergoing decompressive surgery reported greater improvement regarding leg pain, back pain, and overall disability. The relative benefit of initial surgical treatment diminished over time, but outcomes of surgery remained favorable at 2 years. Longer follow-up is needed to determine if these differences persist.
Asunto(s)
Laminectomía , Vértebras Lumbares/cirugía , Estenosis Espinal/rehabilitación , Estenosis Espinal/cirugía , Anciano , Descompresión Quirúrgica , Femenino , Estudios de Seguimiento , Humanos , Vértebras Lumbares/patología , Masculino , Persona de Mediana Edad , Dimensión del DolorRESUMEN
Postgraduate specialist training in medicine is organized in Finland by the country's five medical faculties. Training is completed with a written examination, compulsory since 1962. The recently revised programme comprises 49 specialties, 16 of which stipulate five years, and 33 six years of training. State authorization is provided after successful completion of the programme. In addition, the Finnish Medical Association (FMA) has run a complementary training programme since 1993, covering selected and often interdisciplinary branches of medicine. There are 31 such FMA-authorized training programmes leading to special competence. A training programme for special competence in traffic medicine was approved in 1997, aiming to establish a network of traffic medicine experts throughout the country. The need for doctors trained in traffic medicine is estimated to be 1:100,000 inhabitants. In addition to the seven members of the examination board, 17 doctors have received such special competence.