May 22 2005
The largest ever clinical trial of surgery versus exercise treatments for chronic low back pain has found that patients may obtain as much benefit from an intense physical exercise programme as from spinal surgery.
The results of the MRC Spine Stabilisation trial, led by Mr. Jeremy Fairbank of the Nuffield Orthopaedic Centre, Oxford were published online in today's BMJ.
Chronic low back pain (LBP) is one of the most common ailments that GPs and consultants have to treat. For nearly 90 years the same method of spinal surgery has been used to treat low back pain. There has however, been little evidence to support the assumption that surgery is more effective than the best exercise treatments.
The study, funded by the Medical Research Council (MRC), was carried out in 15 hospitals in England and Scotland. A total of 349 patients aged 18-55 years, suffering with chronic low back pain for at least a year, were randomly selected to groups for spinal surgery or for a three-week intensive physical exercise programme. Half of the patients were assigned to each treatment.
The type of surgery chosen was that considered best for the particular patient. The rehabilitation included cognitive behavioural therapy as well as the three-week programme of exercise.
The researchers, found that, although a few of the patients that underwent surgery had slightly more relief of symptoms compared to patients who were given the exercise programme and cognitive behavioural therapy, the results were not clinically significant enough to suggest that surgery was more beneficial.
Patients in both groups reported improvement in the two year follow-up, with less pain and disability and more mobility. In the absence of an untreated control group it cannot be claimed that this longer-term benefit is due to these treatments, though other studies suggest that this group of patients do not normally improve with time without treatment. A control group of observational or usual treatment was not deemed acceptable to patients with chronic pain unresponsive to physiotherapy, analgesics or chiropractic treatment.
Mr. Jeremy Fairbank, Consultant Orthopaedic Surgeon at the Nuffield Orthopaedic Centre, Oxford, and principal investigator for the MRC Stabilisation Trial, said: "Our results suggest that patients eligible for surgery should be offered this type of rehabilitation programme first, with strong support from the surgeon. We believe it is safer and cheaper than using surgery as the first line of treatment, when conventional physiotherapy and alternative therapy have failed. This type of rehabilitation is well within the capacity of ordinary physiotherapy departments to deliver".
A concurrent study of the economics of the two treatment programmes suggests that a strategy of intensive rehabilitation in the first instance was half the price of a surgical strategy, even though 28% of those allocated to rehabilitation eventually went to have surgery. This part of the study was directed by Dr Alistair Gray of the Institute of Health Sciences.