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¿Pueden influir las variables epidemiológicas el resultado a los 2 años de una cirugía por enfermedad lumbar degenerativa en términos de calidad de vida, discapacidad y dolor postoperatorio?
Can epidemiological factors affect the 2-year outcomes after surgery for degenerative lumbar disease in terms of quality of life, disability and post-surgical pain?
C. Lozano-Álvareza,
Autor para correspondencia
carlos.lozano.alvarez@gmail.com

Autor para correspondencia.
, D. Pérez-Prietob, G. Saló-Brub, A. Molinab, A. Lladób, E. Cáceresc,d, M. Ramírezb
a Orthopaedic Surgery and Trauma Deparment, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
b Servicio de Cirugía Ortopédica y Traumatología Parc de Salut Mar (Hospitals del Mar i la Esperanza), Barcelona, España
c Universitat Autónoma de Barcelona (UAB), Barcelona, España
d Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitari Vall d¿Hebron, Barcelona, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El dolor lumbar cr&#243;nico es uno de las principales entidades cl&#237;nicas que afectan al sistema osteomuscular&#44; con una elevada incidencia &#40;85&#37;&#41; y prevalencia &#40;84&#37;&#41; en los pa&#237;ses industrializados<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El proceso diagn&#243;stico y el tratamiento del dolor lumbar cr&#243;nico &#40;DLC&#41; y de las entidades incluidas dentro de la patolog&#237;a lumbar degenerativa &#40;PLD&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41; suele requerir de intervenciones que generan un elevado gasto sanitario<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Pese a ello&#44; la realizaci&#243;n de dichas intervenciones en las &#250;ltimas d&#233;cadas ha tenido un gran aumento&#44; por ejemplo&#44; en Estados Unidos el n&#250;mero anual de fusiones lumbares por PLD ha aumentado de 174&#46;223 intervenciones en 1998&#44; a 413&#46;171 en 2008&#44; siendo ya la primera causa de artrodesis en el raquis<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">El DLC y la PLD son considerados entidades cl&#237;nicas de origen multifactorial&#46; De igual forma&#44; los resultados de las intervenciones realizadas para tratarlos est&#225;n influidos por diversos factores&#44; tanto f&#237;sicos&#44; psicol&#243;gicos y sociales&#44; de los cuales muchos de ellos son factores epidemiol&#243;gicos&#44; como la edad&#44; la situaci&#243;n laboral&#44; el nivel de estudios y el tabaquismo&#44; entre otros<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a>&#46; Persistiendo&#44; a&#250;n a d&#237;a de hoy&#44; controversias en algunos de ellos&#44; como el caso de la edad<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;14</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo de nuestro estudio ha sido el de evaluar si los factores epidemiol&#243;gicos afectan a los resultados posquir&#250;rgicos de las cirug&#237;as por PLD en t&#233;rminos de calidad de vida&#44; discapacidad y dolor cr&#243;nico en nuestra poblaci&#243;n&#44; pretendiendo aportar nueva informaci&#243;n para as&#237; ayudar a mejorar el proceso de selecci&#243;n de los pacientes y la indicaci&#243;n quir&#250;rgica por PLD&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Aportamos una serie de casos retrospectiva de 263 pacientes intervenidos quir&#250;rgicamente entre 2005 y 2008 por PLD y que completaron los cuestionarios en el preoperatorio &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Hubo 42 p&#233;rdidas de seguimiento &#40;16&#37;&#41;&#44; 35 no localizados y 7 fallecidos&#44; que no completaron los cuestionarios a los 2 a&#241;os&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Se incluy&#243; en el estudio a aquellos pacientes que cumpl&#237;an los siguientes criterios de inclusi&#243;n&#58; ser mayor de edad&#44; haber sido diagnosticado de alguna de las entidades cl&#237;nicas considerada como PLD y haber sido intervenido por esta causa durante el periodo anteriormente citado&#46; Fueron excluidos del estudio aquellos pacientes que presentaban una barrera idiom&#225;tica que impidiera la correcta comprensi&#243;n de los cuestionarios&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Los datos epidemiol&#243;gicos recogidos durante el estudio fueron la edad&#44; el sexo&#44; la situaci&#243;n laboral previa a la intervenci&#243;n y el grado de comorbilidad mediante la escala de la <span class="elsevierStyleItalic">American Society of Anesthesiologist</span> &#40;ASA&#41;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a>&#44; tambi&#233;n se registraron el diagn&#243;stico cl&#237;nico y el procedimiento quir&#250;rgico realizado&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La calidad de vida se evalu&#243; mediante el <span class="elsevierStyleItalic">Medical Outcomes Study Short Form-36 version 2 &#40;SF-36&#41;</span><a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#44; la discapacidad con el <span class="elsevierStyleItalic">Oswestry Disability Index</span> &#40;ODI&#41;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a>&#44; el <span class="elsevierStyleItalic">Core Outcomes Measures Index &#40;COMI&#41;</span><a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> se utiliz&#243; para evaluar de forma global a los pacientes y escalas visuales anal&#243;gicas &#40;EVA&#41;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> para el dolor lumbar y ci&#225;tico en el preoperatorio y a los 2 a&#241;os&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Todos ellos se completaron por los pacientes durante la visita preoperatoria&#44; en la que tambi&#233;n fueron registrados los factores epidemiol&#243;gicos&#44; y a los 2 a&#241;os de la intervenci&#243;n&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">El estudio estad&#237;stico fue realizado mediante el paquete estad&#237;stico SPSS 15&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#41;&#46; Las variables cuantitativas &#40;an&#225;lisis pre-post&#41; se analizaron mediante el test t de Student para datos dependientes&#46; Para comparar los valores medios de la diferencia de los resultados preoperatorios y postoperatorios de los cuestionarios en las variables categ&#243;ricas&#44; se utiliz&#243; el test t de Student para datos independientes en el caso de las variables dicot&#243;micas &#40;sexo&#41; y ANOVA para las variables categ&#243;ricas &#40;ASA y actividad laboral&#44; siendo dicot&#243;micos los valores de las diferentes categor&#237;as de dichas variables&#41;&#46; El an&#225;lisis intergrupos en aquellas variables donde se hallaron diferencias significativas en el ANOVA se realiz&#243; mediante el test <span class="elsevierStyleItalic">Honestly-Significant-Difference</span> de Tukey&#46; El estudio de la correlaci&#243;n entre las variables cuantitativas estudiadas y la variaci&#243;n de los resultados de los cuestionarios fueron realizados mediante el <span class="elsevierStyleItalic">coeficiente de correlaci&#243;n de Pearson</span>&#46; Y&#44; finalmente&#44; le realiz&#243; un estudio de regresi&#243;n lineal m&#250;ltiple para identificar la existencia de posibles factores predictores del cambio de los resultados de los cuestionarios&#46; Para ello se tomaron como posibles variables predictoras independientes aquellas variables epidemiol&#243;gicas cualitativas dicot&#243;micas y cuantitativas&#44; con resultados significativos en los estudios de comparaci&#243;n de medias y de correlaci&#243;n&#44; respectivamente&#44; y como variables dependientes los valores del cambio de los diferentes cuestionarios&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0055" class="elsevierStylePara elsevierViewall">La edad media de la muestra era de 54 a&#241;os &#40;rango 22 a 86&#41;&#46; De los 263 pacientes&#44; 38 &#40;14&#44;8&#37;&#41; ten&#237;an 40 a&#241;os o menos y 74 &#40;29&#37;&#41; ten&#237;an 65 a&#241;os o m&#225;s&#59; 131 de los pacientes &#40;49&#44;8&#37;&#41; eran mujeres&#44; 146 &#40;55&#44;5&#37;&#41; estaban activos previamente a la cirug&#237;a&#44; 33 &#40;12&#44;5&#37;&#41; presentaban incapacidad laboral temporal &#40;ILT&#41;&#44; en otros 33 &#40;12&#44;5&#37;&#41; el grado de incapacidad era permanente y&#44; finalmente&#44; 43 &#40;16&#44;3&#37;&#41; estaban jubilados&#46; Las principales causas de cirug&#237;a fueron la patolog&#237;a degenerativa del disco intervertebral con 98 casos &#40;37&#44;3&#37;&#41; y el canal lumbar estrecho con 82 &#40;31&#44;2&#37;&#41;&#46; Los procedimientos m&#225;s frecuentes la artrodesis intersom&#225;tica lumbar transforaminal &#40;TLIF&#41; realizada en 90 casos &#40;34&#44;2&#37;&#41; y la artrodesis posterolateral instrumentada &#40;APLI&#41; en 84 &#40;31&#44;9&#37;&#41;&#46; En 173 casos &#40;65&#44;8&#37;&#41; se produjo alg&#250;n tipo de descompresi&#243;n de canal medular&#46; El 173 &#40;65&#44;8&#37;&#41; pacientes presentaban un grado <span class="elsevierStyleSmallCaps">ii</span> de comorbilidad seg&#250;n la escala ASA &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Se observ&#243; una mejor&#237;a estad&#237;sticamente significativa a los 2 a&#241;os en el valor medio de los resultados en todos los cuestionarios&#44; con excepci&#243;n de la dimensi&#243;n salud mental &#40;SM&#41; del SF-36 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">La comparaci&#243;n de los resultados medios seg&#250;n el g&#233;nero mostr&#243; c&#243;mo los varones ten&#237;an una mayor mejor&#237;a significativa que las mujeres en el Componente F&#237;sico &#40;CSF&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41; y Componente Mental &#40;CSM&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#44; as&#237; como en la dimensiones dolor corporal &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;046&#41; y SM &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;014&#41;&#44; y en el dolor ci&#225;tico &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41;&#46; En el caso de la actividad laboral&#44; se observ&#243; c&#243;mo los pacientes con incapacidad laboral permanente y transitoria ten&#237;an una menor mejor&#237;a estad&#237;sticamente significativa de los resultados del ODI que los paciente activos o jubilados &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;048&#41;&#46; De igual manera ocurr&#237;a en el CSF&#44; donde los paciente con ILT presentaban una significativa menor mejor&#237;a que los activos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41;&#44; y los pacientes con ILP la menor mejor&#237;a era significativamente menor que los jubilados &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;042&#41;&#46; Por su parte&#44; en la dimensi&#243;n de vitalidad del SF-36 se observaban &#250;nicamente menor mejor&#237;a significativa de los pacientes con ILT respecto a los paciente jubilados &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Por &#250;ltimo&#44; en la escala ASA solamente se identificaron diferencias estad&#237;sticamente significativas en la dimensi&#243;n funci&#243;n f&#237;sica del SF-36 entre los pacientes con ASA I y III &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; Cabe decir&#44; tanto el grupo de pacientes en paro como los que presentaban una comorbilidad ASA IV&#44; han sido excluidos de los anteriores c&#225;lculos&#44; ya que solo un paciente de ambos grupos pudo ser evaluado a los 2 a&#241;os de la cirug&#237;a&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Los estudio de correlaci&#243;n nos mostraron c&#243;mo el aumento de la edad de los pacientes se correlaciona significativamente con un peor resultado del ODI &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;113&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41; y la CSF del SF-36 &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8211;0&#44;03&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;035&#41;&#46; La intensidad dolor lumbar preoperatorio lo hac&#237;a&#44; por su parte&#44; con una menor mejor&#237;a de la CSM &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8211;0&#44;222&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;048&#41; y la del dolor lumbar postoperatorio &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;278&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; y&#44; finalmente&#44; la intensidad de la ci&#225;tica preoperatoria se correlacionaba significativamente con la mejor&#237;a de la CSM &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;310&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;024&#41; y un peor dolor ci&#225;tico postoperatorio &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;452&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Finalmente&#44; el an&#225;lisis de regresi&#243;n lineal m&#250;ltiple&#44; de entre la posibles variables predictoras halladas en la comparaci&#243;n de los resultados medios de las variables cualitativas y en los estudios correlaci&#243;n realizados con las variables cuantitativas&#44; &#250;nicamente identific&#243; que el hecho de tener una ILP es factor predictor de una menor mejor&#237;a del ODI &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#44;146&#59; IC del 95&#37;&#44; 9&#44;09-29&#44;58&#59; p &#60; 0&#44;01&#41; y del CSF del SF-36 &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8211;8&#44;568&#59; IC del 95&#37;&#44; &#8211;14&#44;88&#44; &#8211;2&#44;26&#59; p &#60; 0&#44;01&#41;&#59; de igual manera que la edad del ODI &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;334&#59; IC del 95&#37;&#44; 0&#44;40-0&#44;98&#44; p &#60; 0&#44;05&#41; y del CSF &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8211;0&#44;228&#44; IC del 95&#37;&#44; &#8211;0&#44;40&#44; &#8211;0&#44;06&#44; p &#60; 0&#44;05&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0080" class="elsevierStylePara elsevierViewall">Los resultados tras cirug&#237;a por PLD est&#225;n influidos por factores f&#237;sicos&#44; psicol&#243;gicos y sociales&#44; como son el sexo&#44; la edad&#44; la situaci&#243;n laboral&#44; el nivel de estudios&#44; el tabaquismo&#44; el que sea la primera cirug&#237;a o una reintervenci&#243;n&#44; los ingresos del paciente&#44; que existan litigios&#44; los cuadros depresivos o una personalidad neur&#243;tica y&#44; por supuesto&#44; el grado de degeneraci&#243;n de las articulaciones y el disco intervertebral&#44; siendo este &#250;ltimo un factor de riesgo significativo de reintervenci&#243;n en cirug&#237;a por hernia discal<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a>&#46; En este estudio&#44; constatamos c&#243;mo en nuestra poblaci&#243;n la calidad de vida&#44; la discapacidad&#44; el bienestar general y el dolor se correlacionan y&#44; en algunos casos&#44; est&#225;n afectados por factores epidemiol&#243;gicos&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Debido a esta afectaci&#243;n multifactorial de los resultados postoperatorios&#44; se ha recomendado la divisi&#243;n de conceptos amplios&#44; como &#171;enfermedad degenerativa del disco&#187; o &#171;dolor lumbar cr&#243;nico&#187;&#44; en entidades cl&#237;nicas relevantes como la &#171;espondilolistesis&#187;&#44; la &#171;estenosis de canal lumbar&#187; o la &#171;hernia discal&#187; porque el diagn&#243;stico en s&#237; es un factor que afecta significativamente a los resultados<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;25&#44;26</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">La edad es una importante y controvertida variable&#44; ya que&#44; pese a que la mayor&#237;a coincide en identificarla como un predictor independiente&#44; unos la identifican seg&#250;n sus estudios como un factor predictor negativo<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;13</span></a> y otros como positivo<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46; En nuestro estudio&#44; al igual que en gran parte de la literatura consultada&#44; se observa que los pacientes j&#243;venes presentan mejores resultados postoperatorios de calidad de vida&#44; discapacidad y dolor<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Manniche et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> identifican&#44; por su parte&#44; al sexo femenino como otro factor negativo en cuanto la mejor&#237;a de la discapacidad&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Seg&#250;n nuestra experiencia&#44; la situaci&#243;n laboral de los pacientes es un factor determinante de los resultados postoperatorios y con nuestro trabajo describimos c&#243;mo la existencia o no de incapacidad laboral permanente afecta de forma relevante a la mejor&#237;a de la calidad de vida y la discapacidad&#46; De igual forma que otras ya lo fueron descritas previamente&#44; como la baja satisfacci&#243;n con el trabajo&#44; la mala situaci&#243;n econ&#243;mica o no percibir una compensaci&#243;n econ&#243;mica en el caso de incapacidad laboral&#44; las cuales son consideradas un factor predictor negativo independiente de la calidad de vida&#44; la discapacidad o el dolor posquir&#250;rgico<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;13&#44;29&#44;30</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Pese a que en nuestro trabajo solamente hemos identificado una d&#233;bil correlaci&#243;n entre el dolor lumbar o ci&#225;tico preoperatorios y los resultados posquir&#250;rgicos&#44; el dolor preoperatorio es una variable que ha sido ampliamente estudiada&#46; Se han publicado c&#243;mo la intensidad del dolor lumbar preoperatorio afecta negativamente tanto al dolor como a los resultados postoperatorios evaluados mediante el COMI<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#8211;32</span></a>&#46; De igual manera&#44; los pacientes con dolor lumbar peor que ci&#225;tico presentan peores resultados tras el tratamiento conservador o quir&#250;rgico<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Aunque no hayan sido revisados expl&#237;citamente en el presente trabajo&#44; el h&#225;bito tab&#225;quico<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;28&#44;29</span></a> y el estado psiqui&#225;trico&#44; principalmente los s&#237;ndromes depresivos<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">39&#44;30&#44;34</span></a>&#44; son 2 destacados factores que tambi&#233;n han sido citados frecuentemente como importantes predictores negativos de la mejor&#237;a discapacidad&#44; la calidad de vida y el dolor lumbar y el dolor ci&#225;tico postoperatorios en los pacientes intervenidos por PLD&#46; Otros factores predictores negativos menores citados en la literatura son los antecedentes de cefaleas de repetici&#243;n&#44; el uso de analg&#233;sicos previos a la intervenci&#243;n&#44; un mal estado funcional previo&#44; las bajas expectativas con el tratamiento y un elevado &#205;ndice de masa corporal<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Como limitaciones del presente estudio&#44; cabe destacar que es una serie de casos retrospectiva no aleatorizada&#44; cuyo n&#250;mero de pacientes y p&#233;rdidas puede dar lugar a una disminuci&#243;n de la sensibilidad para detectar el efecto de las diferentes variables&#44; principalmente las de menor frecuencia&#46; De igual manera&#44; ha de tenerse cuenta como una limitaci&#243;n propia de este estudio la importante amplitud de los rangos de las diferentes variables dado el objetivo de estudiar de forma global a la poblaci&#243;n afectada por PLD&#44; la cual podr&#237;a enmascarar el efecto de alguna variable de un grupo m&#225;s espec&#237;fico de la poblaci&#243;n explorada&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; seg&#250;n nuestros resultados&#44; consideramos que el aumento de la edad y la situaci&#243;n laboral son factores negativos que pueden afectar al resultado posquir&#250;rgico de la patolog&#237;a degenerativa del raquis lumbar evaluado en t&#233;rminos de la calidad de vida y la discapacidad&#44; siendo estos resultados independientes del g&#233;nero&#44; del dolor preoperatorio y de la comorbilidad&#46; En definitiva&#44; con nuestro estudio&#44; reforzamos que una correcta y cuidadosa evaluaci&#243;n preoperatoria de los pacientes es primordial para ayudar en la decisi&#243;n cl&#237;nica del tratamiento para as&#237; poder alcanzar el resultado &#243;ptimo en cada caso&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Nivel de evidencia</span><p id="par0125" class="elsevierStylePara elsevierViewall">Nivel de evidencia <span class="elsevierStyleSmallCaps">iv</span>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Responsabilidades &#233;ticas</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protecci&#243;n de personas y animales</span><p id="par0130" class="elsevierStylePara elsevierViewall">Los autores declaran que los procedimientos seguidos se conformaron a las normas &#233;ticas del comit&#233; de experimentaci&#243;n humana responsable y de acuerdo con la Asociaci&#243;n M&#233;dica Mundial y la Declaraci&#243;n de Helsinki&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidencialidad de los datos</span><p id="par0135" class="elsevierStylePara elsevierViewall">Los autores declaran que han seguido los protocolos de su centro de trabajo sobre la publicaci&#243;n de datos de pacientes y que todos los pacientes incluidos en el estudio han recibido informaci&#243;n suficiente y han dado su consentimiento informado por escrito para participar en dicho estudio&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Derecho a la privacidad y consentimiento informado</span><p id="par0140" class="elsevierStylePara elsevierViewall">Los autores han obtenido el consentimiento informado de los pacientes y&#47;o sujetos referidos en el art&#237;culo&#46; Este documento obra en poder del autor de correspondencia&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicto de intereses</span><p id="par0145" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar si los factores epidemiol&#243;gicos afectan a los resultados de la cirug&#237;a por enfermedad lumbar degenerativa en t&#233;rminos de calidad de vida&#44; discapacidad y dolor cr&#243;nico&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Doscientos sesenta y tres pacientes intervenidos por afecci&#243;n lumbar degenerativa fueron incluidos en el estudio &#40;2005-2008&#41;&#46; Variables epidemiol&#243;gicas&#58; edad&#44; g&#233;nero&#44; situaci&#243;n laboral y comorbilidad&#46; Se completaron en el preoperatorio y 2 a&#241;os tras la cirug&#237;a el <span class="elsevierStyleItalic">Medical Outcomes Study Short Form-36 version 2</span>&#44; <span class="elsevierStyleItalic">Oswestry Disability</span> Index &#40;ODI&#41;&#44; <span class="elsevierStyleItalic">Core Outcomes Measures Index</span> &#40;COMI&#41; y EVA para dolor lumbar y ci&#225;tico&#46; En el an&#225;lisis de los datos&#44; se evalu&#243; la correlaci&#243;n entre variables epidemiol&#243;gicas y el cambio en los resultados de los cuestionarios&#44; as&#237; como&#44; la existencia de factores pron&#243;sticos independientes&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Edad media 54&#44;00 a&#241;os &#40;22-86&#41;&#59; 131 mujeres &#40;49&#44;8&#37;&#41;&#59; 42 p&#233;rdidas de seguimiento &#40;16&#37;&#41;&#46; Se observaron correlaciones significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; entre la edad&#44; el g&#233;nero&#44; la comorbilidad&#44; la incapacidad laboral permanente y el dolor preoperatorio con el cambio del ODI&#44; el COMI&#44; los componentes de salud f&#237;sica y mental y las EVA de lumbar y ci&#225;tico&#46; El an&#225;lisis de regresi&#243;n lineal muestra a las ILP y la edad como variables predictoras del cambio de la discapacidad &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#44;146&#59; IC del 95&#37;&#44; 9&#44;09-29&#44;58&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#44; y &#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;334&#59; IC del 95&#37;&#44; 0&#44;40-0&#44;98&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#44; respectivamente&#41; y de la calidad de vida &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;8&#44;568&#59; IC del 95&#37;&#44; &#8722;14&#44;88&#44; &#8722;2&#44;26&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01 y &#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;228&#44; IC del 95&#37;&#44; &#8722;0&#44;40&#44; &#8722;0&#44;06&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#44; respectivamente&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Seg&#250;n nuestros resultados&#44; hemos de considerar al aumento de la edad y la incapacidad laboral permanente como factores epidemiol&#243;gicos predictores negativos de los resultados tras cirug&#237;a por patolog&#237;a lumbar degenerativa&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Purpose</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To evaluate the influence of epidemiological factors on the outcomes of surgery for degenerative lumbar disease in terms of quality of life&#44; disability and chronic pain&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material and method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total of 263 patients who received surgery for degenerative lumbar disease &#40;2005-2008&#41; were included in the study&#46; The epidemiological data collected were age&#44; gender&#44; employment status&#44; and co-morbidity&#46; The <span class="elsevierStyleItalic">SF-36</span>&#44; <span class="elsevierStyleItalic">Oswestry Disability</span> Index &#40;ODI&#41;&#44; <span class="elsevierStyleItalic">Core Outcomes Measures Index</span> &#40;COMI&#41;&#44; and VAS score for lumbar and sciatic pain were measure before and 2 years after surgery&#46; The correlation between epidemiological data and questionnaire results&#44; as well as any independent prognostic factors&#44; were assessed in the data analysis&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The mean age of the patients was 54&#46;0 years &#40;22-86&#41;&#44; and 131 were female &#40;49&#46;8&#37;&#41;&#46; There were 42 &#40;16&#37;&#41; lost to follow-up&#46; Statistically significant correlations &#40;P<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; were observed between age&#44; gender&#44; co-morbidity&#44; permanent sick leave&#44; and pre-operative pain with changes in the ODI&#44; COMI&#44; physical and SF-36 mental scales&#44; and lumbar and sciatic VAS&#46; Linear regression analysis showed permanent sick leave and age as predictive factors of disability &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#46;146&#59; 95&#37; <span class="elsevierStyleSmallCaps">CI</span>&#58; 9&#46;09 &#8211; 29&#46;58&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;01 and &#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;334&#59; 95&#37; CI&#58; 0&#46;40 &#8211; 0&#46;98&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;05&#44; respectively&#41;&#44; and change in quality of life &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;8&#46;568&#59; 95&#37; CI&#58; -14&#46;88 &#8211; &#8722;2&#46;26&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01 and &#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;228&#44; IC95&#37; CI&#58; &#8722;0&#46;40 &#8211; &#8722;0&#46;06&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;05&#44; respectively&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Based on our findings&#44; age and permanent sick leave have to be considered as negative epidemiologic predictive factors of the outcome of degenerative lumbar disease surgery&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Laminectom&#237;a aislada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dolor corporal&nbsp;\t\t\t\t\t\t\n
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