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SECTION III: REGULAR AND SPECIAL FEATURES: Orthopaedic • Radiology • Pathology Conference: Letters to the Editor

Letter to the Editor: Nonspecific Lower-back Pain: Surgical versus Nonsurgical Treatment

Sivan, Manoj

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Clinical Orthopaedics and Related Research: November 2006 - Volume 452 - Issue - p 287
doi: 10.1097/01.blo.0000238817.48401.5b

To the Editor:

I read with interest an excellent comprehensive review of evidence-based treatments for back pain particularly regarding the current debate of surgical versus nonsurgical multidisciplinary treatment for chronic low back pain.3 I debate the comment by Nordin et al that “it is not known if multimodal programs are more or less costly than surgical intervention”. Review of literature clearly suggests that multimodal programs are definitely less costly when compared with surgical options.2,4

The three main randomized controlled trials on this topic have come from Sweden,1 Norway,2 and the United Kingdom.4 Societal total costs are identified as the sum of direct (health care sector) and indirect costs (production losses). In the UK trial, the direct cost of a functional restoration program (FRP) is significantly less than that of surgical fusion. The cost of a FRP is approximately 1410 GBP ($2622 US), at least four times less expensive when compared with the cost of surgical fusion, which is approximately 6011 GBP ($11,180 US).4 There is agreement on this point in the other two studies as well.1,2 Indirect costs are estimated by return to work rates. The UK and Norway studies did not show any significant difference in return to work rates between the two groups. It is known that the Swedish trial did not have a uniform multidisciplinary rehabilitation arm and thus the results could have been less favorable when compared with surgery.

Considering both costs, the total costs are approximately 7830 GBP ($14,563 US dollars) for surgery when compared with 4526 GBP ($8418 US), a significant difference (p < 0.001) of 3304 GBP ($6145 US).4 The Norway study also showed the total costs to be considerably higher for surgery. Thus, the total cost of a FRP is definitely less than the cost of surgical fusion for chronic low back pain.

Manoj Sivan, DOrth, MRCS

47 Hospital Close, Leicester General Hospital, Leicester, United Kingdom LE5 4WQ


1. Fritzell P, Hagg O, Wessburg P, Nordwall A, Group SLSS. Chronic back pain and fusion: a comparison of three surgical techniques: a prospective multicentre randomized study from the Swedish Lumbar Spine Study Group. Spine. 2002;27:1131-1141.
2. Ivor Brox J, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, Ingebrigtsen T, Eriksen H, Holm I, Koller AK, Riise R, Reikeras O. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine. 2003;28:1913-1921.
3. Nordin M, Balague F, Cedraschi C. Nonspecific lower-back pain: surgical versus nonsurgical treatment. Clin Orthop Relat Res. 2006; 443:156-167.
4. Rivero-Arias O, Campbell H, Gray A, Fairbank J, Frost H, Wilson-MacDonald J. Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial. BMJ. 2005;330:1239-1245.
© 2006 Lippincott Williams & Wilkins, Inc.