Question: In patients with chronic low-back pain and disc
degeneration, how do surgical and nonsurgical treatments compare?
Data sources: MEDLINE and references of review articles.
Study selection and assessment: Randomized controlled trials (RCTs)
that compared surgical with nonsurgical treatment for discogenic back pain.
Studies that focused specifically on comparing injections or other
percutaneous treatments were not included. Study quality was assessed with use
of the checklist for the Consolidated Standards of Reporting Trials.
Main outcome measures: Back-specific disability.
Main results: 4 RCTs (n = 783; age range, 18 to 65 y) met the
inclusion criteria. Surgery in 2 RCTs consisted of posterolateral fusion with
use of iliac crest autograft and a specific type of pedicle screw fixation; in
1 RCT, surgeons chose the surgical approach, implant, interbody cages, and
bone-graft material; and in 1 RCT, patients were randomized to receive 1 of 3
prespecified surgical techniques: posterolateral fusion with iliac crest
autograft and no fixation, posterolateral fusion with iliac crest autograft
and pedicle screw fixation, or circumferential fusion consisting of
posterolateral fusion and fixation supplemented with interbody fusion with use
of autogenous iliac crest bone block inserted anteriorly or posteriorly. One
RCT compared surgery with nonoperative care focused on physical therapy, and
in 3 RCTs the control treatment was cognitive behavioral therapy addressing
fears about back injury. All 4 RCTs measured disability with use of the
Oswestry Disability Index (ODI) (higher score = greater disability). Across
the 4 RCTs, the percent improvement from baseline ranged from 19% to 37% in
the surgery group and from 5.8% to 30% in the nonoperative group. 1 RCT showed
a benefit of surgery over unspecified nonoperative treatment with a difference
in mean change in the ODI of 8.8 points (percent improvement 19%). The other 3
RCTs did not show a clinically meaningful difference in change in ODI score
between surgery and nonoperative treatment (range: in mean change, —3.9
to 3.8%; in improvement, —9.5% to 7.5%). 2 RCTs that reported patient
satisfaction showed greater success with surgery. The complication rate with
surgery ranged from 9% to 18%; no complications were reported for the
nonoperative group in any study.
Conclusions: In patients with chronic low-back pain and disc
degeneration, surgical treatment may be somewhat better than unstructured
nonoperative treatment but has not been shown to be better than cognitive
behavioral therapy.
In the ongoing debate about the efficacy of spinal fusion for the treatment
of back pain, this review by Mirza and Deyo carefully scrutinizes the
literature comparing lumbar fusion with nonoperative management.
Only 4 RCTs fulfilled the criteria for inclusion, highlighting the paucity
of evidence in this field. These studies showed an improvement with surgical
treatment greater than the minimally clinically important difference
determined by the designers of the ODI of 4 points. However, they did not meet
the U.S. Food and Drug Administration's designated threshold for spine fusion
of a =15 point change in the ODI. Although sample size calculations were
performed for all 4 studies, only the studies by Fritzell et al. and Fairbank
et al. were adequately powered to show a true difference.
Mirza and Deyo used the ODI as the main outcome measure common to these
studies. However, Fritzell et al. also evaluated work status, general
function, overall assessment, and depressive symptoms. Fairbank et al.
evaluated the shuttle walking test. The nonoperative group treatment in each
of the 4 studies, while "unstructured," (meaning nonuniform across
and within studies), was intensive, including 3 weeks of daily physical
therapy and a lecture on proper use of the back in one trial; 3 weeks of daily
physical therapy and cognitive therapy in another; and physical therapy,
education, injections, transcutaneous electric nerve stimulation, and
acupuncture in a third.
Mirza and Deyo conclude that surgical therapy may be more efficacious than
unstructured nonoperative care; however, the gains appear to be modest. They
state that "the differences in the magnitude of nonsurgical improvement
suggest that the nature of nonsurgical treatment may be critical." Their
careful review allows comparison across these studies as well as their guarded
conclusion. Given the risk for complications with surgery, it is worth
ensuring that all patients considering surgery for chronic low-back pain and
disc degeneration have completed a course of formal physical therapy with
counseling before embarking on surgery.