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Avoid surgery as first line treatment for non-specific low back pain

BMJ 2014; 349 doi: (Published 16 July 2014) Cite this as: BMJ 2014;349:g4214
  1. Wilco C Peul, professor and chair of neurosurgery12,
  2. Annelien L Bredenoord, associate professor of biomedical ethics3,
  3. Wilco C H Jacobs, health scientist1
  1. 1Department of Neurosurgery, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, Netherlands
  2. 2Department of Neurosurgery, Medical Centre Haaglanden, PO Box 432, 2501 CK The Hague, Netherlands
  3. 3Department of Medical Humanities, Julius Centre, University Medical Centre Utrecht, Netherlands
  1. Correspondence to: W C Peul w.c.peul{at}

Key points

  • For non-specific low back pain (LBP), do not offer spinal surgery as first line treatment, as insufficient evidence exists for greater effectiveness of surgical interventions than conservative treatment

  • Offer surgery only for severe persistent non-specific LBP if multidisciplinary (combined physical and psychological) conservative treatment is ineffective

  • Non-specific LBP should not be confused with sciatica or neurogenic claudication, for which surgery may have a role

  • Magnetic resonance imaging should be performed only if red flags exist or when considering surgery for persistent and severe non-specific LBP for which conservative treatment has been ineffective

Low back pain (LBP) ranks as the number one disorder in terms of years lived with disability; estimated global one year incidences range from 22% to 65%.1 Back pain as a symptom, not attributable to spinal instability caused by trauma, infection, progressive deformity, or tumour, and not associated with radicular symptoms, is labelled non-specific LBP (see box). Many of patients with non-specific LBP may have degenerative intervertebral disc and bony joint changes, including disc herniations and spinal stenosis on imaging, but these findings are not more common than in the general population, including people without LBP.2 Guidelines discourage surgery for non-specific back pain3; some recommend surgery only after two years of failed conservative treatments in carefully selected patients.4 However, despite these recommendations, the rate of back surgery is rising, with considerable geographical variation.5 The rates of spinal fusion, including use of surgical implants, for all degenerative disorders of the lumbar spine show an unexplained exponential increase,6 7 with a corresponding rise in serious perioperative complications, including stroke and cardiopulmonary events.7 These rises are unexpected, as the incidence of spinal diseases causing instability of vertebral elements has not risen, and nor has the incidence of surgery for herniated discs and stenosis. …

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