Surgery or Physical Therapy for Your Back?

Summarized by Robert W. Griffith, MD
September 26, 2005

Introduction

Spinal fusion surgery is quite a common procedure for people with back pain of long duration. Of course, there are many conditions where there is no question about the benefits of spinal fusion - certain types of fractured vertebrae, spinal deformities, or clearly demonstrable spinal instability. However, the use of spinal fusion to treat back pain is somewhat controversial. Many surgeons recommend fusion for low back pain as a last resort and believe it should be considered only after other conservative (non-surgical) measures have failed.

A group of orthopedic surgeons in the UK has done a study of people with chronic low back pain who were considered candidates for spinal fusion. They compared the results of surgery in half of them with intensive physical therapy in the others. The findings are reported in the British Medical Journal, and summarized here.

What was done

Patients who were candidates for spinal fusion for their pain were eligible for the study if they and their doctor were uncertain which of the study treatments would be best. They had to be between 18 and 55, with more than 12 months' chronic low back pain. Fifteen centers in the UK recruited patients; they all had surgeons with training and expertise in performing spinal fusions.

Participants were allocated at random to undergo surgery or physical therapy. The particular technique used for spinal fusion was decided by the operating surgeon. The intensive rehabilitation patients had an average of 75 hours of therapy, given over 5 days a week for 3 weeks. This was followed by one-day sessions at 1, 3, 6, and 12 months later. Physical therapy (stretching, flexibility, muscle-building, and aerobic exercises) linked with cognitive behavioral therapy was the focus of the intensive treatment.¹

The results of both treatments were measured using a back pain questionnaire² and a standardized walking test that assessed speed and endurance.

Complications of surgery were recorded, as well as distress and anxiety, using psychological testing.

What was found

There were 176 patients allocated to receive spinal surgery, and 173 to have intensive therapy. In fact, only 139 and 151 patients, respectively, actually received their allocated treatment.

Both treatments were associated with an improvement in their back pain scores:

	Average Score Before:	Score 2 Years After:
Spinal Fusion	46.5	34.0
Intensive Physical Therapy	44.8	36.1

The before-after difference was slightly greater with spinal fusion, (and statistically significant), but the difference between treatments was very small in comparison with the potential risks and additional costs of surgery. In fact, complications during or immediately after the surgical procedure were reported in 19 cases, and 11 patients required further surgery on their lumbar spine within 2 years.

There were no significant differences in the other ratings of effectiveness between the two treatment groups.

What this means

This study provided no clear evidence that spinal fusion surgery is a better option for patients with chronic low back pain than intensive physical therapy combined with cognitive behavior therapy.

A previous review of published studies, made 5 years ago, came to a similar conclusion. However, two studies done since then have been more optimistic in favor of surgery. So, what is one to believe?

The answer probably lies in further studies - although we hate to have to say that. The details of the patients in most studies do not allow one to break down the results according to types that do better with surgery and types that do better with physical therapy. Until this is clarified, low back pain patients might do best to embark on and complete, if possible, a course of intensive physical and cognitive behavioral therapy. If there is no improvement after a given period, spinal fusion may be advised, after full explanation of the likelihood and nature of possible surgical complications.

One factor that may enter into the decision process for some people is the question of cost. A cost-benefit analysis of the UK study was done and reported in the same journal.³ The average cost per surgical patient was $14,000, compared with $8,100 for intensive physical care with cognitive behavioral therapy. Another reason not to rush into surgery!

Source

• Randomized controlled trial to compare surgical stabilization of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilization trial. J. Fairbank, H. Frost, J. Wilson-MacDonald,  et al., BMJ, 2005, vol. 330, pp. 1233--1239

Footnotes
1. "Cognitive-behavioral" therapy, or CBT, is a type of treatment where patients learn to change their behaviors and beliefs in order to better cope with or relieve a particular problem.
2. The Oswestry low back pain disability index is scored from 0% (no disability) to 100% (totally disabled or bedridden).
3. Surgical stabilization of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomized controlled study. O. Rivero-Arias, H. Campbell, A. Gray,  et al., British Medical Journal, 2005, vol. 330, pp. 1239--1243

Related Links
North American Spine Society: Spinal Fusion Surgery
"Oh - My Aching Back!" -- Part 1
"Oh - My Aching Back!" -- Part 4

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