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Systematic Review of Randomized Trials Comparing Lumbar Fusion Surgery to Nonoperative Care for Treatment of Chronic Back Pain

Mirza, Sohail K., MD, MPH*†‡; Deyo, Richard A., MD, MPH*†§∥

doi: 10.1097/01.brs.0000259225.37454.38
Literature Review

Study Design. Systematic review of randomized trials comparing surgical to nonsurgical treatment of discogenic back pain.

Objective. Compare research methods and results.

Summary of Background Data. Recent reports have increased debate about the role of surgery in the treatment of chronic back pain associated with lumbar disc degeneration. We conducted a systematic review of randomized trials comparing lumbar fusion surgery to nonsurgical treatment of chronic back pain associated with lumbar disc degeneration.

Methods. A literature search identified 5 randomized trials that compared fusion to nonoperative treatment for chronic low back pain. Excluding 1 trial for spondylolisthesis, we compared study participants, interventions, analyses, and outcomes in 4 trials that focused on nonspecific chronic back.

Results. All trials enrolled similar subjects. One study suggested greater improvement in back-specific disability for fusion compared to unstructured nonoperative care at 2 years, but the trial did not report data according to intent-to-treat principles. Three trials suggested no substantial difference in disability scores at 1-year and 2-years when fusion was compared to a 3-week cognitive-behavior treatment addressing fears about back injury. However, 2 of these trials were underpowered to identify clinically important differences. The third trial had high rates of cross-over (>20% for each treatment) and loss to follow-up (20%); it is unclear how these affected results.

Conclusions. Surgery may be more efficacious than unstructured nonsurgical care for chronic back pain but may not be more efficacious than structured cognitive-behavior therapy. Methodological limitations of the randomized trials prevent firm conclusions.

No firm conclusions can yet be drawn from the results of randomized trials comparing lumbar fusion to nonoperative care for chronic back pain.

From the *Center for Cost and Outcomes Research, and Departments of †Orthopedics and Sports Medicine, ‡Neurological Surgery, §Medicine, and ∥Health Services, University of Washington, Seattle, WA.

Acknowledgment date: June 26, 2006. Acceptance date: August 4, 2006.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

Corporate/Industry and Federal funds were received in support of this work. Although one or more of the author(s) has/have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript, benefits will be directed solely to a research fund, foundation, educational institution, or other nonprofit organization which the author(s) has/have been associated.

Address correspondence and reprint request to Sohail K. Mirza, MD, MPH, Associate Professor, Department of Orthopaedics and Sports Medicine, And Department of Neurological Surgery, Harborview Medical Center, University of Washington, Box 359798, 325 Ninth Avenue, Seattle, WA 98104-2499; E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.