Surgery Not the Best Solution for Chronic Back Pain

Researchers compared results of outcomes of community-based surgical and nonsurgical treatments for patients with chronic back pain attributed to degeneration at one or two lumbar disc levels and found that any improvements were marginal one year after surgery.

“The degree of improvement we observed in surgical patients was marginal despite intensive concurrent treatments. These findings are relevant to guiding policy and practice for this patient population in the United States. Facilitating effective treatments based on trustworthy clinical practice guidelines may yield large benefits at the population level,” Sohail K. Mirza, M.D., M.P.H., and colleagues wrote.

The researchers identified 495 patients with discogenic back pain who consulted with 16 surgeons at their offices for a first-time surgical consultation to discuss treatment options. Eighty-six patients (17 percent) underwent surgery within six months of enrollment in the study, which consisted of instrumented fusion (79 percent), disc replacement (12 percent), or laminectomy or discectomy (9 percent).

In the study results, the primary outcome that Mirza and colleagues used—back-specific disability—showed an advantage for surgery. In the linear mixed models that were adjusted for baseline measures associated with surgery and for loss to follow-up, the patients in the study who had surgery within the first six months had Roland scores that were, on average, 5.4 points (95 percent CI: 3.9–6.9, P<.001) lower than the nonsurgical group after one year or six months to 12 months after surgery (9.6 months mean), according to Mirza and colleagues.

“Secondary outcomes also showed advantage for surgery, including overall pain intensity rating, composite measures of success, and other physical and mental health measures,” the investigators wrote. “Patients showed variable improvement on both the overall pain rating and Roland back disability scales, but the surgical group had greater improvement than the nonsurgical group at all potential cut-off thresholds for defining success.”

These results should be interpreted cautiously because outcomes are short term, and treatment was not randomly assigned, Mirza and colleagues noted. In addition, 5 percent of nonsurgical patients received cognitive behavior therapy and the nonsurgical interventions they underwent were variable and may not have been compliant with major guidelines, according to the study results.