Lumbar Fusion: Relief at a Price

There’s a steep price associated with lumbar fusion surgery. And it doesn’t involve money.

A study has concluded the procedure is a valid treatment option for chronic low back pain, but the surgery usually is accompanied by substantial postoperative pain and disability. “Lumbar fusion for non-specific low back pain is still the most controversial subject in spine surgery,” with previous studies producing conflicting data on the efficacy of fusion compared with standard physiotherapy, noted Rune Hedlund, M.D., a professor at Sahlgrenska University Hospital in Sweden.

Hedlund and his colleagues in the Swedish Lumbar Spine Study Group enrolled 294 patients (150 male, 144 female) with chronic low back pain lasting at least two years with radiographs showing degenerative disc disease. The patients randomly received either lumbar fusion or standard physiotherapy; roughly 26 percent of physiotherapy patients eventually underwent surgery but were not included in the fusion group.

“This represents the largest study with the longest follow-up thus far conducted, and is also the one with the highest follow-up rate so far presented — 92 percent — unique for a long-term study,” Hedlund told Spinal News International. “This allows for stronger conclusions than in previous studies, which are characterized by low follow-up rates.”

The primary outcome measure used was patient global assessment as well as Oswestry Disability Index (ODI) scores, visual analogue scale (VAS) pain scores, Zung depression index, medication use, pain frequency and ability to work.

According to the data, 65 percent of fusion patients reported either “better” (39 percent) or “much better” (26 percent) global assessment scores compared with 37 percent of patients in the physiotherapy group (26 percent “better” and 11 percent “much better”) (p=0.044). But both groups improved in all secondary outcome variables to similar levels at 13 years, Hedlund said. ODI scores for the fusion group showed an improvement of 11 points, while VAS back pain scores improved by 18 points. Working status (full- or part-time) did not differ significantly between the two groups, improving from 21 percent at baseline to 38 percent after 13 years in the fusion group, compared with 24 percent through 41 percent  int he physiotherapy group. In addition, 43 percent of patients in the fusion group and 41 percent in the physiotherapy group reported “always” having pain (p=0.95) at a 13-year follow-up.

Compared with previous studies, the Group’s results found “a better global assessment for fusion than for conservative treatment in contrast to a combined British-Norwegian study.” Hedlund also said the marginal improvements in pain levels and disability noted in the study were similar to those found by others, including systematic reviews.

“Patient global assessment was better for the fusion group than for the physiotherapy group, despite similar pain, functional ability and working status,” Hedlund said. “From a patient’s perspective, lumbar fusion can still be considered a valid treatment option for chronic low back pain. However, substantial remaining pain and disability should be expected after fusion.”