From the Guidelines
The decision between spinal fusion and intensive rehabilitation for nonradicular low back pain should be highly individualized, considering the patient's specific pathology, functional limitations, response to conservative care, and personal preferences after thorough discussion of the uncertain long-term outcomes. While spinal fusion surgery is commonly performed for chronic low back pain, the research comparing it to intensive rehabilitation programs has not shown reliable, sustained advantages over time 1. This is important because spinal fusion is an invasive procedure with potential complications including infection, nerve damage, hardware failure, and adjacent segment disease. Additionally, fusion permanently alters spine biomechanics and requires significant recovery time.
Key Considerations
- The lack of consistent long-term benefit evidence suggests that intensive rehabilitation with a cognitive behavioral emphasis may be a preferable initial approach for many patients with nonradicular low back pain.
- Before considering surgery, patients should typically undergo a comprehensive conservative treatment approach including physical therapy, pain management, and cognitive behavioral therapy for at least 6-12 months.
- The choice between surgical and non-surgical approaches should be based on a thorough discussion of the potential benefits and risks, as well as the patient's individual circumstances and preferences.
Evidence-Based Recommendations
- Intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation may be considered for patients with chronic or subacute low back pain 1.
- Spinal manipulation administered by providers with appropriate training is associated with small to moderate short-term benefits for acute low back pain 1.
- The optimal time to start exercise therapy after the onset of symptoms is unclear, but other guidelines suggest starting exercise after 2 to 6 weeks 1.
From the Research
Caveat to Spinal Fusion versus Intensive Rehabilitation
The caveat to spinal fusion versus intensive rehabilitation for nonradicular low back pain is that the evidence suggests that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function 2.
- Spinal fusion may be slightly to moderately superior to standard (nonintensive) nonsurgical therapy, but less than half of patients experience optimal outcomes following fusion 2.
- A long-term follow-up study of three randomized controlled trials found no statistically or clinically significant differences between treatment groups for Oswestry Disability Index scores at long-term follow-up (average 11.4 years) 3.
- The results suggest that, given the increased risks of surgery and the lack of deterioration in nonoperative outcomes over time, the use of lumbar fusion in chronic low back pain patients should not be favored in health care systems where multidisciplinary cognitive-behavioral and exercise rehabilitation programmes are available 3.
Prognostic Tests for Lumbar Spinal Fusion
Several prognostic tests are used to select patients for lumbar spinal fusion, including immobilization in a lumbosacral orthosis, provocative discography, and trial immobilization by temporary external transpedicular fixation. However:
- A systematic review found that the accuracy of all prognostic tests was low, and that no subset of patients with low back pain could be identified for whom spinal fusion is a reliable and effective treatment 4.
- The use of these tests is not supported by best evidence, and spinal fusion should not be proposed as a standard treatment for chronic low back pain 4.
Current Surgical Treatments for Chronic Low-Back Pain
A recent evidence-based review of the current surgical treatments for chronic low-back pain found that:
- Spinal fusions are not superior in terms of Oswestry Disability Index function or pain level, but do outperform nonoperative management without intensive rehabilitation therapy 5.
- A comprehensive approach to the management of chronic low back pain is recommended, including evaluation for surgical approaches when anatomical causes have been identified and multidisciplinary strategies have been implemented 5.