Top

Published in:

01-02-2008 | Original Paper

Surgical versus non-surgical treatment of chronic low back pain: a meta-analysis of randomised trials

Authors: T. Ibrahim, I. M. Tleyjeh, O. Gabbar

Published in: International Orthopaedics | Issue 1/2008

Abstract

We performed a meta-analysis of randomised controlled trials to investigate the effectiveness of surgical fusion for the treatment of chronic low back pain compared to non-surgical intervention. Several electronic databases (MEDLINE, EMBASE, CINAHL and Science Citation Index) were searched from 1966 to 2005. The meta-analysis comparison was based on the mean difference in Oswestry Disability Index (ODI) change from baseline to the specified follow-up of patients undergoing surgical versus non-surgical treatment. Of the 58 articles identified, three studies were eligible for primary analysis and one study for sensitivity analysis, with a total of 634 patients. The pooled mean difference in ODI between the surgical and non-surgical groups was in favour of surgery (mean difference of ODI: 4.13, 95%CI: −0.82 to 9.08, p = 0.10, I² = 44.4%). Surgical treatment was associated with a 16% pooled rate of early complication (95%CI: 12–20, I² = 0%). Surgical fusion for chronic low back pain favoured a marginal improvement in the ODI compared to non-surgical intervention. This difference in ODI was not statistically significant and is of minimal clinical importance. Surgery was found to be associated with a significant risk of complications. Therefore, the cumulative evidence at the present time does not support routine surgical fusion for the treatment of chronic low back pain.

Andersson GB (1999) Epidemiological features of chronic low pain. Lancet 354:581–585PubMedCrossRef

Andersson HI, Ejlertsson G, Leden I, Rosenberg C (1993) Chronic pain in a geographically defined general population: studies of differences in age, gender, social class and pain localization. Clin J Pain 9:174–182PubMedCrossRef

Brox JI, Sørensen R, Friis A, Nygaard Ø, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikerås O (2003) Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 28:1913–1921PubMedCrossRef

Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G (1994) An international comparison of back surgery rates. Spine 19:1201–1206PubMedCrossRef

Christensen FB, Bünger C (2004) Stabilisation surgery for chronic low back pain: indications, surgical procedures, and outcome. Scand J Rheumatol 33:210–217PubMedCrossRef

DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188PubMedCrossRef

Deyo RA, Gray DT, Krueter W, Mirza S, Martin BI (2005) United States trends in lumbar fusion surgery for degenerative conditions. Spine 30:1441–1445PubMedCrossRef

Ekman P, Möller H, Hedlund R (2005) The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study. Spine J 5:36–44PubMedCrossRef

Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Baker K, Collins R (for the Spine Stabilisation Trial Group) (2005) Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. Br Med J 330:1233–1239CrossRef

10.

Fairbank JCT, Pynsent PB (2000) The oswestry disability index. Spine 25:2940–2953PubMedCrossRef

12.

Fritzell P, Hägg O, Wessberg P, Nordwall A (2001) 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain. A multicenter randomised controlled trial from the Swedish Lumbar Spine Study Group. Spine 26:2521–2534PubMedCrossRef

13.

Fritzell P, Hägg O, Wessberg P, Nordwall A (2002) Chronic low back pain and fusion: a comparison of three surgical techniques. A prospective multicenter randomised study from the Swedish Lumbar Spine Study Group. Spine 27:1131–1141PubMedCrossRef

11.

Fritzell P, Hägg O, Jonsson D, Nordwall A (2004) Cost-effectiveness of lumbar fusion and nonsurgical treatment for chronic low back pain in the Swedish Spine Study: a multicenter, randomized, controlled trial from the Swedish Lumbar Spine Study Group. Spine 29:421–434PubMedCrossRef

14.

Gibson JNA, Grant C, Waddell G (1999) The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis. Spine 24:1819–1832CrossRef

15.

Herkowitz H (1995) Lumbar spine fusions in the treatment of degenerative conditions: current indications and recommendations. J Am Acad Orthop Surg 3:123–135PubMed

16.

Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. Br Med J 327:557–560CrossRef

17.

Juni P, Altman DG, Egger M (2001) Systematic reviews in health care: assessing the quality of controlled clinical trials. Br Med J 323:42–46CrossRef

18.

Kanwaldeep S, Herkowitz HN (1997) Spinal instrumentation in the management of degenerative disorders of the lumbar spine. Clin Orthop 335:39–53

19.

Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikerås O (2003) Trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine 29:3–8CrossRef

20.

Meade TW, Dyer S, Browne W, Townsend J, Frank AO (1990) Low back pain: comparison of chiropractic and hospital outpatient treatment. Br Med J 300:1431–1437CrossRef

21.

Meta-analysis of change scores of the Cochrane Handbook (Section: 8.6.4.2). http://cochrane.dk/cochrane/handbook/8_analysing_and_presenting_results/8.6_summarising_effects_across_studies.htm

22.

McAfee PC, Lee GA, Fedder IL, Cunningham BW (2002) Anterior BAK instrumentation and fusion: complete versus partial discectomy. Clin Orthop 394:55–63PubMedCrossRef

23.

Moher D, Cook JD, Eastwood S, Olkin I, Rennie D, Stroup DF (1999) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Lancet 354:1896–1900PubMedCrossRef

24.

Möller H, Hedlund R (2000) Surgery versus conservative management in adult isthmic spondylolisthesis. A prospective randomized study: Part 1. Spine 25:1711–1715PubMedCrossRef

25.

Möller H, Sundin A, Hedlund R (2000) Symptoms, signs, and functional disability in adult spondylolisthesis. Spine 25:683–689PubMedCrossRef

26.

Nachemson A (1985) Recent advances in the treatment of low back pain. Int Orthop 9:1–10PubMedCrossRef

27.

Rivero-Arias O, Campbell H, Gray A, Fairbank J, Frost H, Wilson-MacDonald J for the Spine Stabilisation Trial Group (2005) Surgical stabilisation 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 randomised controlled trial. Br Med J 330:1239–1243CrossRef

28.

Taylor SJ, Taylor AE, Foy MA, Fogg AJB (1999) Responsiveness of common outcome measures for patients with low back pain. Spine 24:1805–1812PubMedCrossRef

29.

Thomsen K, Christensen FB, Eiskjaer SP, Hansen ES, Fruensgaard S, Bünger CE (1997) 1997 Volvo Award winner in clinical studies. The effect of pedicle screw instrumentation on functional outcome and fusion rates in posterolateral lumbar spinal fusion: a prospective, randomised clinical study. Spine 22:2813–2822PubMedCrossRef

30.

van Tulder MW, Assendelft WJ, Koes BW, Bouter LM (1997) Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for Spinal Disorders. Spine 22:2323–2330PubMedCrossRef

Title: Surgical versus non-surgical treatment of chronic low back pain: a meta-analysis of randomised trials
Authors: T. Ibrahim
I. M. Tleyjeh
O. Gabbar
Publication date: 01-02-2008
Publisher: Springer-Verlag
Published in: International Orthopaedics / Issue 1/2008
Print ISSN: 0341-2695
Electronic ISSN: 1432-5195
DOI: https://doi.org/10.1007/s00264-006-0269-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Surgical versus non-surgical treatment of chronic low back pain: a meta-analysis of randomised trials

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 1/2008

Functional outcome in patients with osteosarcoma around the knee joint treated by minimised surgery

Awareness and use of intertrochanteric osteotomies in current clinical practice. An international survey

Comment on Changulani et al. “Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study”

Preoperative bone quality as a factor in dual-energy X-ray absorptiometry analysis comparing bone remodelling between two implant types

Posterolateral fusion using laminectomy bone chips in the treatment of lumbar spondylolisthesis

A new classification and guide for surgical treatment of spinal tuberculosis