BMJ  2005;330:1220-1221 (28 May), doi:10.1136/bmj.330.7502.1220

Editorial

Surgery versus intensive rehabilitation programmes for chronic low back pain

Spinal fusion surgery has only modest, if any, effects

The optimal management of patients with chronic low back pain remains a big challenge for today's healthcare services. In this week's BMJ Fairbank et al report how they assessed the effectiveness of surgical stabilisation of the spine compared to an intensive rehabilitation programme for patients who had had low back pain of at least a year and who were considered candidates for spinal fusion.¹ The authors found no clear evidence that primary spinal fusion surgery was more beneficial than intensive rehabilitation, supporting the idea that spinal fusion plays, at best, only a small role in managing chronic low back pain.

The relevant and informative randomised trial by Fairbank et al was pragmatic by design.¹ Patients with chronic low back pain were eligible for inclusion if neither they nor their doctors were certain about which treatment might be better. Patients in the surgery group were operated on by surgeons using a surgical technique of their choice. Patients allocated to the rehabilitation programme followed an intensive training programme for some 75 days, with individually tailored daily exercises, hydrotherapy, and cognitive behaviour therapy. Four additional follow-up sessions were scheduled during the next year and, in both groups, patients improved, although the surgery group scored better on just one of the primary outcome measures, the Oswestry disability index.

Clearly, the improvements over time were rather similar in both groups and, as the authors suggest, may well have occurred independently of the interventions. But the trial did not include an untreated control group. In addition, many patients in both arms of the trial still had considerable disability after two years.

Current clinical guidelines for managing chronic low back pain do not recommend spinal fusion, except for a very carefully selected and limited group of patients, so these do not have to be changed in the light of this new study.^{2 3} Spinal fusion seems to help some patients with chronic low back pain. However, we must find ways to identify these patients in advance using valid and reliable classification systems. Until then spinal fusion may, after all these years, still be regarded as an experimental treatment.

A Cochrane review on spinal fusion for degenerative lumbar spondylosis concluded five years ago that there was no adequate scientific evidence for the efficacy of spinal fusion surgery: most of the included trials compared different surgical techniques, but included no conservative treatment arm.⁴ Two subsequent trials for patients with chronic low back pain have reported conflicting results. Fritzell et al reported reductions in disability and pain two years after lumbar fusion, compared to non-surgical treatments.⁵ This study was criticised, however, for the choice of included patients. For example, patients were eligible only if previous non-surgical treatment was unsuccessful, and it was not clear whether the type and intensity of the non-surgical treatment might have been suboptimal.⁶ The second study by Brox et al reported equal improvement with lumbar fusion compared to a cognitive behavioural intervention plus exercises for patients who had chronic low back pain and degeneration of spinal discs.⁷

If there is no firm evidence on surgery for chronic low back pain, are intensive rehabilitation programmes a relevant treatment option for patients? A Cochrane review summarising 10 trials concluded that intensive, multidisciplinary, biopsychosocial rehabilitation aimed at restoring function improves chronic low back pain and function, whereas less intensive interventions do not yield improvements in clinically relevant outcomes.⁸ In accordance with this, the recently issued European clinical guidelines recommend multidisciplinary rehabilitation for patients with chronic low back pain who have failed monodisciplinary treatments,² and several national clinical guidelines also support this approach.³ Nevertheless, it is still important to determine which patients will benefit most from such rehabilitation and will be suitable for entering these programmes.

¹ Department of General Practice, Erasmus MC, University Medical Center Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands (b.koes{at}erasmusmc.nl)

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Competing interests: None declared.

Papers pp 1233, 1239

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: 1233-9.[Abstract/Free Full Text]
2. European Commission Research Directorate General. COST B13 Management Committee. European guidelines for the management of low back pain. 2005. www.backpaineurope.org (accessed 18 May 2005).
3. Koes BW, van Tulder MW, Ostelo R, Burton AK, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26: 2504-13.[CrossRef][ISI][Medline]
4. Gibson JNA, Waddell G, Grant IC. Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev 2000;(3): CD001352.
5. Fritzell P, Hagg O, Wessberg P, Nordwall A, and the Swedish Lumbar Spine Study Group. 2001 Volvo award winner in Clinical studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain. Spine 2001;26: 2521-34.[CrossRef][ISI][Medline]
6. Mooney V. Point of View - 2001 Volvo award winner in Clinical studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain. Spine 2001;26: 2532-3.[CrossRef]
7. Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28: 1913-21.[CrossRef][ISI][Medline]
8. Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary bio-psycho-social rehabilitation for chronic low-back pain. Cochrane Database Syst Rev 2002;(1): CD000963.

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