Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain

Spine (Phila Pa 1976). 2007 Apr 1;32(7):816-23. doi: 10.1097/01.brs.0000259225.37454.38.

Abstract

Study design: Systematic review of randomized trials comparing surgical to nonsurgical treatment of discogenic back pain.

Objective: Compare research methods and results.

Summary of background data: Recent reports have increased debate about the role of surgery in the treatment of chronic back pain associated with lumbar disc degeneration. We conducted a systematic review of randomized trials comparing lumbar fusion surgery to nonsurgical treatment of chronic back pain associated with lumbar disc degeneration.

Methods: A literature search identified 5 randomized trials that compared fusion to nonoperative treatment for chronic low back pain. Excluding 1 trial for spondylolisthesis, we compared study participants, interventions, analyses, and outcomes in 4 trials that focused on nonspecific chronic back.

Results: All trials enrolled similar subjects. One study suggested greater improvement in back-specific disability for fusion compared to unstructured nonoperative care at 2 years, but the trial did not report data according to intent-to-treat principles. Three trials suggested no substantial difference in disability scores at 1-year and 2-years when fusion was compared to a 3-week cognitive-behavior treatment addressing fears about back injury. However, 2 of these trials were underpowered to identify clinically important differences. The third trial had high rates of cross-over (>20% for each treatment) and loss to follow-up (20%); it is unclear how these affected results.

Conclusions: Surgery may be more efficacious than unstructured nonsurgical care for chronic back pain but may not be more efficacious than structured cognitive-behavior therapy. Methodological limitations of the randomized trials prevent firm conclusions.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Back Pain / psychology
  • Back Pain / therapy*
  • Chronic Disease
  • Cognitive Behavioral Therapy / methods*
  • Disability Evaluation
  • Humans
  • Intervertebral Disc / pathology
  • Intervertebral Disc / surgery*
  • Lumbar Vertebrae / surgery
  • Middle Aged
  • Randomized Controlled Trials as Topic
  • Spinal Diseases / surgery*
  • Spinal Fusion / methods*
  • Treatment Outcome