Aspectos medicolegales y bioéticos de la cirugía instrumentada de la columna lumbar degenerativa. Implicaciones en el manejo del dolor crónico

Abstract

Evidence-based medicine has still not been able to demonstrate the advantages of surgical treatment over medical therapy in patients with chronic degenerative lumbar and sciatic pain. Personal, professional and economic conflicts are involved in this disorder, and are the subject of the present article. The reputation of certain physicians is seen as a desirable asset by some companies that would like to associate it with their products. Continuing medical training is another area that can involve conflicts of interest, since every dollar invested returns a benefit of almost four-fold. Patients generally leave decisions on surgery and the technique to be used in the hands of their physicians, overestimating the results that will be obtained. Wide variability in medical practice in fusion surgery has been detected among similar countries and among regions within the same country. Patients older than 65 years can sometimes accept high surgical risk, either because of the type of intervention proposed, without using the new technologies of minimally-invasive surgery and without taking full advantage of interventionist antialgic techniques. Likewise, patients also accept a high risk of complications resulting from the long-term use of opioids when surgery is not performed. Medico-legal and bioethical conflicts are proliferating both in the media and in specialized journals with free online access. An avalanche of lawsuits can be expected against the health service that employs us. These lawsuits will affect not only physicians but also the institutions where we work and, subsidiarily, our private insurance policies. Fraudulent marketing in the field of pain is generating multimillion fines. The results of this type of surgery in terms of occupational recovery are highly discouraging. Very few patients recover minimal capacity to work or report a high level of physical functioning after the intervention. Research in this field should focus on the creation or organisms or national consortiums to control and fund research, which should be free of the direct involvement of industry. Because of the increase in health expenditure, mechanisms for the evaluation of health technologies are important. To rationalize and perform cost accounting of funding in public health services for this disorder and surgical techniques, new diagnosis-related groups (DRG) should be created specifically for chronic pain and, in particular, for fusion surgery in the degenerative spine. It falls to the central and/or autonomic health services to stimulate the creation of clinical pathways or guidelines for the management of these patients, both in primary and specialized care. The accreditation of Multidisciplinary Pain Units by the health service is urgently required, especially in general hospitals where spinal fusion surgery is performed. Adequate staff and technical resources should be available in these units and should be clearly defined by the corresponding national and international scientific societies.