Systematic Review of Randomized Trials Comparing Lumbar Fusion Surgery to Nonoperative Care for Treatment of Chronic Back Pain

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.