From the Guidelines
Surgical intervention for chronic low back pain should be reserved for specific conditions with clear anatomical causes, as it shows limited effectiveness for non-specific low back pain. The American College of Physicians and the American Pain Society guideline [ 1 ] emphasizes the importance of evaluating patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (MRI) or computed tomography (CT) only if they are potential candidates for surgery or epidural steroid injection.
Key Considerations
- For patients with herniated discs and radiculopathy, surgery provides faster symptom relief than conservative treatment, but long-term outcomes are similar [ 1 ].
- For spinal stenosis, decompression surgery offers moderate benefits compared to non-surgical management, with approximately 60-70% of patients reporting meaningful improvement [ 1 ].
- For degenerative spondylolisthesis with spinal stenosis, fusion plus decompression appears more effective than decompression alone [ 1 ].
- However, for non-specific low back pain, there is insufficient evidence supporting surgical intervention, and fusion surgery shows outcomes similar to intensive rehabilitation programs [ 1 ].
Risks and Benefits
- The benefits of surgery must be weighed against risks including infection, bleeding, nerve injury, and failed back surgery syndrome [ 1 ].
- Patient selection is crucial, with better outcomes typically seen in those with specific pathoanatomical diagnoses, concordant symptoms and imaging findings, and failure of appropriate conservative management for at least 6-12 months [ 1 ].
Treatment Approach
- Clinicians should provide patients with evidence-based information on low back pain, advise patients to remain active, and provide information about effective self-care options [ 1 ].
- For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits, such as intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation [ 1 ].
From the Research
Effectiveness of Surgical Intervention for Managing Chronic Low Back Pain
The effectiveness of surgical intervention for managing chronic low back pain is a topic of ongoing debate. According to 2, surgical treatment options for patients with chronic low back pain include lumbar fusion, lumbar disc arthroplasty, and dynamic stabilization. However, the study notes that the surgical outcome still remains questionable due to the lack of a precise identification of the cause of chronic low back pain in any given patient.
Surgical Options and Their Efficacy
- Lumbar fusion remains the most frequent spine surgery performed for chronic low back pain, but questions still exist regarding its efficacy in comparison with conservative care or interventional pain management 2.
- Lumbar disc arthroplasty and dynamic stabilization can be considered only for select patients with chronic low back pain, and their uses are currently limited 2.
- The evidence for surgical fusions and disc replacement is similar, without superiority when compared with multidisciplinary biopsychosocial rehabilitation, well-designed physical therapy, or epidural injections 3.
Recommendations for Surgical Intervention
- Surgical intervention should be reserved for patients with severe and debilitating symptoms and, with careful selection, can result in good outcomes with rapid return to function 4.
- Patients with chronic low back pain should be evaluated for surgical approaches when anatomical causes have been identified and multidisciplinary strategies have been implemented 5.
- The current evidence strongly advocates for a comprehensive approach to the management of chronic low back pain, considering all available strategies, including surgical interventions, pharmacological and noninterventional procedures 5.
Comparison with Other Treatments
- Spinal fusions are not superior in terms of Oswestry Disability Index function or pain level, but they do outperform nonoperative management without intensive rehabilitation therapy 5.
- Multidisciplinary biopsychosocial rehabilitation, well-designed physical therapy, or epidural injections may be as effective as surgical interventions in managing chronic low back pain 3.