Summary Statement: Treatment of the Painful Motion Segment (2005)

In this issue, Spine addresses the painful motion segment. There are various neurophysiologic reasons why the motion segment can be a source of pain. This issue addresses the new technologies for the surgical treatment of these patients. There is a tremendous variation in rates of procedures and choice of techniques throughout the world. This variation reflects the uncertainty of optimal treatment. There are insufficient data comparing different treatment options to recommend preferred techniques. With the rapid rate of innovation, there has been a convergence of rapidly evolving technology. Simultaneous use of multiple new technologies makes it more difficult to discern which is the cause for success. This rapid change makes long-term analysis problematic, if not impossible. There is a lack of high-quality outcome data for operative and nonoperative management of the painful motion segment and a paucity of long-term follow-ups. Further, there is a discrepancy in the published literature for length of follow-up comparing different treatment methods. Clearly, differences in the risk-to-benefit ratio exist; yet, the data for care are limited on all sides of this issue. Conventional open posterior and anterior fusion techniques will be reviewed as well as a variety of techniques to restore or reconstruct the motion segment. In addition, this issue addresses some newer fusion techniques as well as new motion-preserving or restoring alternatives. It is unclear which patients will optimally benefit from any given technique. Hopefully, the collaboration between government, industry, philanthropists, and private payers will provide the necessary resources to conduct high-quality, much needed studies. With the advent of motion technology, there is a great initial excitement among clinicians and patients. The long-term implications of this paradigm shift, however, are unknown. It appears, in the short-term, that patients have equivalent results with the hope for a decrease in the rate of adjacent segment degeneration. To date, this remains unproven but makes intuitive and biomechanical sense. The rate of revisions and rates of outcome expectations for these devices are unknown. It is also unknown if the decreased rate of resumed adjacent segment degeneration is worth the increased reoperation rate for eventual failure of some of these devices. Improvements in techniques will have limited success due to limitation of accurate diagnosis. Until we are able to do a better “pain scan” to localize the pain generator, our surgical success rate can be no better than our diagnostic success rate. In evaluating results, both technical and outcome considerations need to be evaluated. Finding a better way to achieve a fusion or to restore motion should be assessed by radiologic parameters. Outcome measures then should be disease-specific (i.e., Oswestry Disability Index) as well as by generalizable tools (i.e., SF-36). Although these two results are both important, they can be independent. Not only are the new implants expensive, but teaching the application of these implants, not only to the physicians but to the nursing and operating room staff takes time and finances. A steep learning curve is present in planting these devices, and also, they are expensive and have associated morbidity. Treatment of the painful motion segment of the spine can now be done in a variety of methods. Hopefully, being able to make the correct diagnosis and relying on better outcome data will determine which patient may benefit from these new motion-preserving or motion-restoring devices.