Surgery and Low Back Pain -- Is the Choice Clear?

From Medscape Family Medicine > Best Evidence Review

Charles P. Vega, MD

Background

Low back pain is a very common condition, accounting for 2.3% of physician visits in the United States.
The total cost of low back pain exceeds $100 billion per year in the United States alone.
Two-thirds of these costs are related to lost wages and decreased productivity at work.
A small minority of patients with severe back pain account for a significant majority of the total socioeconomic cost of back pain.
Thus, it is not surprising that surgical treatment for low back pain has grown more widespread over the past 20 years.
The analysis of long-term data discussed in this review suggests that surgery is not superior to a short, intensive cognitive and exercise intervention among patients with common low back pain.
This research suggests that surgical treatment for chronic low back pain may be overused.

In an analysis of 2 national surveys performed in the United States in 2002, 26.4% of respondents reported a history of back pain lasting at least 1 day during the previous 3 months.
The prevalence of back pain was inversely related to educational attainment and income, and the rate of back pain appeared stable compared with estimates from the previous decade.

The practice dictum states that low back pain nearly always resolves spontaneously. This may be true, but important caveats are needed.
One study found that although the majority of patients discontinue seeking medical care for their low back pain, nearly 80% of these patients continued to experience some pain or disability at 1 year following their initial clinic visit for low back pain.
In a more recent study of 973 primary care patients with less than 2 weeks of low back pain, the rates of returning to work were approximately 50% at 14 days and 83% at 3 months.
However, these statistics belied the median recovery times for disability (31 days) and pain (58 days). Only 72% of participants reported complete recovery at 12 months.

The fact that many patients have lingering symptoms, in combination with the introduction and promotion of new surgical techniques and equipment, has led to an explosive increase in the use of surgery for low back pain. The estimated number of lumbar fusion procedures increased by an estimated 134% between 1993 and 2003; other estimates have suggested a more than 200% increase in the number of these procedures during a similar time frame.

But does surgery afford better outcomes to patients with chronic low back pain? Several studies have examined this issue.
A previous large trial of surgery for lumbar spondylolisthesis and spinal stenosis demonstrated that surgery did not improve pain or disability compared with usual care on intent-to-treat analysis.
However, significant crossover between the surgery and usual care groups occurred in this research, and as-treated analyses found that surgery improved pain, function, and disability at 2 years compared with usual care.

This research was important and provocative, but not necessarily definitive. Moreover, it did not compare surgery with an active intervention.
Previously, the authors of the current study reported on outcomes at 1 and 2 years in a comparison of lumbar fusion with a program of cognitive intervention and prescribed exercises among patients with chronic low back pain.
They found that outcomes were similar in the surgical and nonsurgical groups. However, given the chronic nature of low back pain among many patients, it remained unclear if their results would continue to remain the same in the very long term. The current study addresses this issue with a report from their patient cohort at 4 years.

Clinical Pearls

* More than one fourth of Americans have experienced significant back pain in the past 3 months, and the total cost of low back pain exceeds $100 billion per year in the United States alone;
* Surgical treatment of low back pain has become more prevalent;
* In the current study, an intensive, brief program of cognitive and exercise treatment produced similar outcomes as surgical treatment of chronic low back pain;
* The current study is in accord with previous systematic reviews of treatment for low back pain without significant anatomic changes (such as spinal stenosis) or symptoms (such as radiculopathy); and
* Further research could highlight how to use elements of the intensive back rehabilitation program in everyday practice