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Surgery for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline

Chou, Roger, MD*†; Baisden, Jamie, MD, FACS; Carragee, Eugene J., MD§; Resnick, Daniel K., MD; Shaffer, William O., MD; Loeser, John D., MD**

doi: 10.1097/BRS.0b013e3181a105fc
Literature Review

Study Design. Systematic review.

Objective. To systematically assess benefits and harms of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis.

Summary of Background Data. Although back surgery rates continue to increase, there is uncertainty or controversy about utility of back surgery for various conditions.

Methods. Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of the above therapies. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.

Results. For nonradicular low back pain with common degenerative changes, we found fair evidence that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard (nonintensive) nonsurgical therapy. Less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion. Clinical benefits of instrumented versus noninstrumented fusion are unclear. For radiculopathy with herniated lumbar disc, we found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. For symptomatic spinal stenosis with or without degenerative spondylolisthesis, we found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. For both conditions, patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up in some trials. Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease and that an interspinous spacer device is superior to nonsurgical therapy for 1- or 2-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge long-term benefits or harms.

Conclusion. Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.

For nonradicular low back pain with common degenerative changes, fusion is no more effective than interdisciplinary rehabilitation, but slightly to moderately more effective than standard nonsurgical therapy. Surgery is moderately more effective than nonsurgical therapy for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis, though benefits diminish with longer duration of follow-up in some trials.

From the Department of *Medicine, and †Medical Informatics and Clinical Epidemiology, Oregon Evidence-based Practice Center, OR Health and Science University, Portland, OR; ‡Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI; §Department of Orthopedic Surgery, Stanford University, Stanford, CA; ¶Department of Neurosurgery, University of Wisconsin, Madison, WI; ∥Department of Orthopaedics, University of Kentucky, Lexington, KY; and **Department of Neurological Surgery, University of Washington, Seattle, WA.

Acknowledgment date: October 21, 2008. Revision date: December 19, 2008. Acceptance date: December 22, 2008.

Supported by the American Pain Society (APS).

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

Professional organizational funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

This article is based on research conducted at the Oregon Evidence-based Practice Center. The authors are solely responsible for the content of this article and the decision to submit for publication. No statement in this article should be construed as an official position of the APS.

Registered products and procedures: BAK Interbody Fusion System, Zimmer Spine Europe, Africa, & Middle East, Sulzer Allee 8, P.O. Box, CH- 8404 Winterthur; Coblation Technology, ArthroCare Corporation, 7500 Rialto Boulevard, Building 2, Suite 100, Austin, TX 78735; CHARITÉ Artificial Disc/Procedure, DePuy Spine, a Johnson & Johnson company 2004–2007, 325 Paramount Drive, Raynham, MA 02767; DEKOMPRESSOR, Stryker Instruments, 4100 East Milham Avenue, Kalamazoo, MI 49001; Ovid, 33 Seventh Avenue, 20th Floor, New York, NY 10001; Prodisc II & Prodisc-L, Synthes Spine, Inc., 1302 Wright Lane East, West Chester, PA 19380; X-STOP Nonfusion Surgical Implant, Kyphon Inc., 1221 Crossman Ave, Sunnyvale, CA 94089.

Address correspondence and reprint requests to Roger Chou, MD, 3181 SW Sam Jackson Park Road, Mail code BICC, Portland, OR 97239; E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.