We read with interest the comments of Dr. Sivan concerning our paper, “Nonspecific lower-back pain: surgical versus nonsurgical treatment”,1 and would like to acknowledge his interest in our work.
The outcomes of surgery to treat chronic nonspecific low back pain are indeed an important issue. We have commented on the mostly favorable results of multidisciplinary and/or multimodal programs in terms of pain, functional, psychologic, and employment status, as compared with surgery where available, and stressed that, contrary to surgery, these programs have no documented complications.
Studies evaluating the benefits of multimodal programs do not all include cost-effectiveness analyses as an outcome. Furthermore comparing these programs is far from straightforward as they may vary to a large extent in terms of contents, duration, setting, etc, and thus in terms of costs. We definitely agree with Dr. Sivan on the quality and the interest of the economic analysis published by Rivero-Arias et al.2 We also agree with his interpretation of the published figures. However, in our analysis we have considered aspects not highlighted by our debater. All three randomized control trials mentioned by Dr. Sivan were conducted in European countries benefiting from social security systems so that what the results might be should similar studies be done in other health systems in wealthy countries (eg, Australia, Japan, USA) or in developing countries remains an open question. Besides, the calculations of costs seem rather “short term” considering the mean age of patients with low-back pain. It is also noteworthy that all three trials evaluate one specific surgical procedure, ie, spinal fusion.
For these reasons we still contend that a straightforward conclusion asserting that multimodal programs are definitely less expensive than surgical procedures (mostly fusion studies), may not be valid worldwide and we thus subscribe to our more conditional wording.
Margareta Nordin, DrSci
Departments of Orthopaedics and Environmental Medicine, School of Medicine, New York University, New York, NY;
Federico Balagué, MD
Department of Rheumatology and Rehabilitation, Fribourg Canton Hospital, Fribourg, Switzerland;
Christine Cedraschi, PhD
Multidisciplinary Pain Centre, Service of Clinical Pharmacology and Toxicology, & Division of General Medica Rehabilitation, Geneva University Hospitals, Geneva, Switzerland
1. Nordin M, Balagué F, Cedraschi C. Nonspecific lower-back pain: surgical versus nonsurgical treatment. Clin Orthop Relat Res
2. 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