Surgery -- Or No Surgery for Chronic Low Back PainPatients with chronic, persistent, and disabling low back pain from degenerative disc disease (DDD) will be interested in the results of this study. The authors (surgeons from four well-known Spine Centers in the U.S.) collected, reviewed, and summarized data from studies comparing surgical fusion with nonoperative (conservative) care.
They used careful selection criteria to get the best evidence possible. Studies included had to use validated patient assessment tools to measure outcomes (e.g., the Oswestry Disability Index, Short Form Health Survey). Patient satisfaction and X-ray results were also acceptable measures of clinical outcomes.
Articles considered unacceptable for review (inclusion) and therefore excluded were: 1) based on opinion, 2) only reporting on surgical technique, or 3) included patients receiving a fusion at more than two spinal levels. In addition, studies that were too small (less than 20 patients) or too short (follow-up was less than one year) were not included.
Twenty-six (26) studies with a total of over 3,000 patients met the necessary standards to be included. All patients had pain and loss of function as a result of degenerative disc disease in the lumbar spine (low back). Spinal surgery done was fusion at one or two levels.
The authors provided several summaries of data (in table form) from studies that compared results of surgery versus nonoperative care for this condition. The tables showed specific information compiled for randomized and nonrandomized controlled trials. They included length of follow-up time, patient age, baseline back pain information, change in outcome scores, fusion rates, reoperation rates, and level of patient satisfaction.
Overall patient satisfaction was 75 per cent for patients who had the fusion procedure, while patients in the nonoperative group reported a much lower rate (55.6 per cent) of satisfaction. The percentage of patients who had a successful fusion was 84 per cent. Seven per cent (7%) of the total group had a second surgery due to a failed first surgery.
Pain relief and improved function were reported for the fusion patients in the majority of cases. Type of fusion technique and age of the patient (young versus old) did not seem to affect success of the fusion procedure.
Patients evaluating results of surgery versus nonoperative care for degenerative disc disease should keep in mind that these two treatments are not really competing with one another. Patients aren't usually given the opportunity to choose between them.
Instead, treatment is offered in a series: first conservative care with medications, physical therapy, and rest. Then, if the treatment fails, follow-up surgery (spinal fusion) is advised. Surgeons who seek the best evidence available to support their clinical decisions may rely on systematic reviews like this one to direct and guide them.
Summary: Collecting information on treatment results like in this review (especially success and failure risks and rates) is important today because of the large number of people missing work or seeking medical care for chronic low back pain. The high cost of fusion surgery also warrants knowing if surgical care is the best way to go.
As this systematic review showed, patients who do not get relief from their painful, disabling symptoms with nonsurgical treatment may find surgical fusion is a very good next step in the treatment algorithm (clinical decision pathway).
Frank M. Phillips, MD, et al. Lumbar Spine Fusion for Chronic Low Back Pain Due to Degenerative Disc Disease. In Spine. April 1, 2013. Vol. 38. No. 7. Pp. E409-E422.
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