Surgery for chronic low back pain is no better than intensive rehabilitation

Surgery for chronic low back pain is no better than intensive rehabilitation and is unlikely to be a cost-effective use of scarce healthcare resources, show two studies published online by the BMJ.

These results should help doctors and service providers make decisions about the management of chronic low back pain.

Chronic low back pain, defined as pain lasting for more than 12 months, is common and places a major economic burden on individuals, the healthcare system, and society as a whole. Direct costs were estimated to be around £1.6bn in the United Kingdom in 1998, and the condition is estimated to account for close to 120 million UK work days lost per year.

The trial involved 349 chronic back pain patients from 15 centres across the UK. 176 patients were assigned to spinal fusion surgery and 173 to an intensive programme of rehabilitation, led by physiotherapists, involving daily exercises and cognitive (mental) behavioural therapy.

After two years, 38 patients assigned to rehabilitation had received rehabilitation and surgery, whereas just seven surgery patients received both treatments. There appeared to be a slight advantage to surgical treatment, but the differences were small considering the potential risk and additional cost of surgery.

The authors conclude that there is no clear evidence that spinal fusion surgery is any more beneficial than rehabilitation, and suggest that rehabilitation should be routinely available to chronic low back pain patients.

In the cost analysis, the average total cost per patient was estimated to be £7830 in the surgery group and £4526 in the rehabilitation group, a significant difference of £3304.

The authors conclude that a policy of spinal fusion surgery as first line therapy for chronic low back pain seems not to be a cost effective use of healthcare resources at two year follow-up. However, this could alter if the number of rehabilitation patients subsequently receiving surgery continues to increase in the future.