Kronik Diskojenik Bel Ağrıları ve Cerrahi Dışı Tedavi Yöntemleri: Güncelleme

ntervertebral diskten kaynaklanan bel ağrısı birbiriyle iliş- kili ama birbirinden ayrı iki etiyoloji ile tarif edilmiştir ki bun- lar disk herniasyonu ve diskojenik ağrıdır. Diğer sebepler dışlandığında, diskojenik ağrı prevalansının %17-42 ara- sında olduğu bildirilmiştir. Tanısal modaliteler klinik mua- yene, görüntüleme ve diskografi olup provokatif diskografi tanı için altın standart olmaya devam etmektedir. Tedavi yöntemleri arasında ilaç tedavisi, fizyoterapi modaliteleri, multidisipliner biyopsikososyal rehabilitasyon gibi invaziv olmayan tedaviler; intradiskal tedaviler ve epidural enjek- siyonlar gibi girişimsel modaliteler ve son olarak füzyon ve yapay disk replasmanı gibi cerrahi yaklaşımlar yer alır. Kronik diskojenik bel ağrısında ilaç tedavisi için kanıtlar steroid olmayan anti-inflamatuar ilaçlar ve çok sayıda istenmeyen sonuca sebep olabildiği bilinen opioidlerle sınırlıdır. Bel okulu ve özgün egzersiz programları gibi başka birçok fiziksel ve davranışsal terapi yöntemleri için sınırlı düzeyde kanıt vardır. İnvaziv olmayan tedavilerin diğer modalitelerle birlikte uygulandığında hastalar için ek faydalar sağlayabildiği gösterilmiştir. Multidisipliner bi- yopsikososyal rehabilitasyon için kanıtlar orta düzeydedir. Kronik diskojenik bel ağrısının tedavisinde epidural enjek- siyonlar için kanıtlar orta düzeyde iken intradiskal tedavi- ler için kanıtlar genel anlamda zayıftır. Cerrahi füzyonlar ve disk replasmanı için kanıtlar benzerdir ve birden çok branşın katıldığı biyopsikososyal rehabilitasyon ya da iyi tasarlanmış fizik tedavi ile karşılaştırıldığında üstün olma- dığı bildirilmiştir. Birden çok otorite cerrahi yaklaşımların potansiyel komplikasyonlarına dikkat çekmiş ve endikas- yonunu konservatif tedavilere yanıtsız seçilmiş vakalarla sınırlı tutmuştur. Gelecekte en ümit verici tedaviler, birden çok branşın katıldığı ve devam eden egzersiz program- larını içeren rehabilitasyon programları ve/veya epidural enjeksiyonlar gibi görünmektedir. Optimal tedavi moda- litelerini belirleyebilmek için yeterli örneklem büyüklüğü ve uzun dönemli takip içeren yüksek kalitede randomize kontrollü çalışmalar tasarlanmalıdır

Chronic Discogenic Low Back Pain and Non-Surgical Treatment Methods: An Update

Low back pain originating from intervertebral disc is de- scribed by two separate but related etiologies: disc her- niation and discogenic pain. When other causes are ex- cluded, prevalence of discogenic pain was reported to be between 17-42%. Diagnostic modalities include clinical examination, imaging, and discography and provoca- tive discography remains to be the golden standard for diagnosis. Treatment methods include noninvasive ap- proaches such as drugs, physiotherapy modalities, and multidisciplinary biopsychosocial rehabilitation; invasive approaches such as intradiscal treatments and epidural injections; and lastly surgical approaches such as fusion and artificial joint replacement. Evidence for drug treat- ment in chronic discogenic low back pain is limited to nonsteroidal anti-inflammatory drugs and opioids which are associated with many adverse outcomes. It has been shown that when noninvasive methods are used together with other modalities patients may obtain additional ben- efits. Evidence base is limited for many other physical and behavioral treatment methods like low back school and specific exercise programs. There is moderate evidence for epidural injections and poor evidence for intradiscal treatments. Evidence for surgical fusions and disc re- placements are similar and it is not superior to multidis- ciplinary biopsychosocial rehabilitation or well-designed physical treatment. Multiple authorities have emphasized potential complications and limited the indication of sur- gical approaches to patients who do not response con- servative treatments. In future, the most promising treat- ments seem to be multidisciplinary and long-term exer- cise programs and/or epidural injections. High quality ran- domized controlled studies with adequate sample sizes and long term follow ups should be designed in order to determine optimal treatment modalities

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Dicle Tıp Dergisi-Cover
  • ISSN: 1300-2945
  • Yayın Aralığı: Yılda 4 Sayı
  • Başlangıç: 1963
  • Yayıncı: Cahfer GÜLOĞLU
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