What if back surgery was a drug?BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39619.499583.3A (Published 26 June 2008) Cite this as: BMJ 2008;336:1452
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The definition of Intervertebral Disc Disease has varied through times. Vesalio described it for the first time in the year 1555. Two centuries later the Italian Domingo Cotugno described ciatic as a clinical entity which was named Cutagno Disease since then. In 1874 Virchow stated that he had found a traumatic hernia of pulpy nuclei. Later in 1911, Goldtwart described the intervertebral disc hernia or proplapse of the intervertebral disc as an entity.
In 1938 Lore and Wasch, published the first hundred patients surgically treated and stated that lumbar cytalgia was only a symptom and that the prolapse of the pulpy core is the most common cause of radicular compression in the lumbar spine.
But, what has happened with this concept since then? Revolutionary and new elements that influence upon the topic have made physicians reflect on the topic due to the fact that the development of technology (images and endoscopies) have arisen new concepts in regard to the origin of the radicular damage, not directly for the compression of the intervertebral disc but because of other factors such as foramens’ stenosis due to fibrosis, protrusion of joint coverings, local irritations due to fissures and fenestration of the fibrous ring that allow that the toxic components that constitute the pulpy core star an inflammatory process due to chemical irritation. These situations can only be solved via other types of surgeries with a more direct visualization than the one offered by the microscope or than the simple sight of the surgeon with the technique of non assisted microscopy, means that are unable to see those orifices, curves or foramens. Hence, the concept of the intervertebral disc hernia has evolved to lumbar disc disease or lumbar disc pathology that is a wider phenomenon that includes an additional number of medico-pathological situations related to intervertebral disc hernias, without being them as such.
The solution to these situations is therefore great dilemmas for the open classic technique, whether assisted or not.
In our institution, 384 cases have been assisted in a three year-period, 126 patients out of the total were treated surgically (32.8%) and the remaining 258 affected patients had medical treatment. The therapeutic decision is based on the Clinical Practical Guidelines which constitute the technical foundation for the medical treatment of patients with prolapsed intervertebral disc.
1. Vagg M. Prolapsed intervertebral disc: What if back surgery was a drug? BMJ 2008; 336: 1452 (28 June).
2. Fairbank J. Prolapsed intervertebral disc. BMJ 208; 336: 1317-8 (14 June).
3. Weber H. spine update: history of disc herniation and the influence of intervention. Spine 1994; 19: 2234-8.
Competing interests: No competing interests