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Three Part Question

[In patients presenting with simple, non-neurological chronic back pain] is [spinal fusion better than conservative] at [reducing pain and facilitating a return to normal activities]

Clinical Scenario

A 45 year old patient presents with a 2 year history of low back pain. He has had to give up his job as a sign painter as a result of his problem which has resulted in siginificant financial problems for him and his family. He describes no red flag symptoms and has no specific neurological signs. He has been previously investigated with plain X-rays and MR scan which have revealed degenerative disease of the lumbar spine. He wants to know if surgery is an option for the relief of his pain.

Search Strategy

Cochrane database of systematic reviews 2005 Edition 2.
Medline 2004 to May 2005. OVID interface via ATHENS
Cochrane
Spinal and fusion
Medline
[back pain.mp. or exp Back Pain/ or exp Back Pain/ or exp Low Back Pain/ or lumbar pain.mp.] and [fusion.mp.] limit to humans and english language and abstracts

Search Outcome

Cochrane. 17 citations of which one was directly relevant to the 3 part question. This was last searched in 2004.
Medline. 77 papers found of which no more relevant papers were found.
One additional paper was found from a recent publication.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fairbank J et al 2005 UK	349 patients aged 18-55 with chronic low back pain. Patients were eligible if there was uncertainty in the mind of the clinician and patient about the benefits of surgery. Patients were either treated with surgery (technique chosen by surgeon) or intensive rehabilitation (about 75 hours initially with follow up at 1,3,6, and 12 months).	PRCT	Follow up rates	284/349 (81%) completed the 24 month follow up period	19% drop out rate (though they do try and account for this in the analysis). Great deal of crossover between treatments. Very intensive rehab program not available in many centres
			Oswestry back disability index	34 for surgery vs 36.1 for conservative management (difference of 4.1 (CI -8.1 to -0.1) in favour of surgery p=0.045
			Shuttle walking test	Better for surgery 352 vs 310 (Difference of 34 (CI -8 to 77) p=0,12
			SF 36 physical component score	28.8 for surgery vs 27.6 for conservative (p=0.21)
			Adjustment for missing patients	No significant change in conclusions
			Comp,iance with treatment allocation	Analysis was by intention to treat. 48(28%) of the patients allocated to conservative management underwent surgery within 2 years.
Gibson JNA et al 2005 UNK	RCTs and quasi RCTs of surgical treatment for lumbar spondylosis. The authors included trials of spondylosis or degenerative disc disease.Interventions included laminectomy; laminotomy; anterior lumbar intervertebral body (ALIF), postero-lateral, posterior lumbar intervertebral body (PLIF) fusion, alone or in combination, or other forms of instrumented fusion; intradiscal electrotherapy (IDET), disc arthroplasty; combinations of the preceding interventions.	Systematic review and meta-analysis	Number of relevant trials found	31 trials found.	This is a high quality review that addresses many aspects of surgical treatment. Only the results pertaining to simple chronic, non-neurological back pain are given here.
			Quality of trials found	Variable. More recent studies of higher quality.
			Surgery for back pain without neurological compromise	2 recent trials with conflicting results. Surgery beneficial when compared to "usual care" but no better when compared to active rehabilitation program. Fusion is more effective than continued, failed, standard 1990s, 'usual care'; Surgery does not appear to be any more effective than a modern rehabilitation programme.

Comment(s)

Spinal fusion has been a controversial therapy for chronic back pain. The review and recent RCT shown here indicate that in cases where clinical uncertainty exists as to the utility of surgery then there is unlikely to be significant improvements in patient outcomes. It should be noted that these results do not refer to patients with neurological compromise.

Clinical Bottom Line

Spinal Fusion is not indicated for simple chronic low back pain.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Fairbank J, Frost H, Wilson-MacDonald J, Yu L, Barker K, Collins R for the Spine Stabilisation Trial Group Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial BMJ 2005;330;1233-
2. Gibson JNA, Waddell G. Surgery for degenerative lumbar spondylosis The Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001352. DOI: 10.1002/14651858.CD001352.pub2.