Dynamic stabilization devices in the treatment of low back pain

Soft stabilization has an important role in the treatment of the degenerative lumbar spine. Fusion of one or two motion segments may not make a big difference in the total range of motion of the lumbar spine, but preserving flexibility of a motion segment may prevent adjacent segment disease and may permit disc replacement, even when facet joints need to be excised. If a favorable environment is created in the motion segment by unloading the disc and permitting near normal motion, the disc may be able to repair itself or may supplement the reparative potential of gene therapy. Although soft stabilization seems promising, one should take a cautious approach to any new implant system. An implant for fusion only has to serve a temporary stabilization until fusion has taken place; on the other hand, a soft stabilization system has to provide stability throughout its life. Implant loosening following fusion surgery is common in the presence of pseudarthrosis. After soft stabilization, the implant has to stay anchored to the bone despite allowing movement. This sounds like a daunting task. The flexibility of the implant system, however, should be able to protect it from loosening at the anchor point into the bone. Finally, the soft stabilization system is intended to load-share with the disc and the facet joint only partially and unloads the motion segment. Any mismatch between the kinematics of the implant system and the motion segment, in particular any discrepancy between their IAR, would result in the implant bearing unexpected load at certain ranges of motion. If that happens, it would guarantee an early implant failure or loosening. The need for strict bench testing in the laboratory, therefore, cannot be over-emphasized. The few soft stabilization systems that have had clinical applications so far have produced a clinical outcome comparable to that of fusion. No prospective randomized controlled trial has been reported yet, which is an essential requirement for practice of evidence-based medicine.