RAPID RESPONSES FROM BMJ.COM

Fairbank et al reported a randomized controlled trial of surgical stabilization of the lumbar spine compared to intensive rehabilitation program in patients with chronic low back pain.¹ The principle of randomization was based on a “gray zone” of uncertainty (on behalf of the treating clinician) as to whether surgical stabilization or an intensive rehabilitation program was the appropriate management (ie, that there was clinical equipoise as to whether the patient should have surgery or non-surgical treatment).

Many spinal surgeons including myself would not feel that this is an area where clinical equipoise is possible. If a patient is thought to be appropriate for an intensive rehabilitation program then that is what should occur. Surgery is contraindicated until all conservative treatments have been exhausted, including an intensive rehabilitation program. A …