New Studies Examine Short- and Long-Term Results of Surgical and Non-Operative Treatments for Back Pain

According to two studies published recently in The Spine Journal, patients reported limited, positive short-term benefits to surgical vs. non-operative care, yet the long-term benefit did not seem to hold up when comparing treatment options for chronic low back pain. Patient access to and compliance with non-operative treatment programs appear to deliver results comparable to surgery, but with fewer risks and lower costs, according to the study’s authors.

“Despite major advances in spine research, technology and treatment, the long-term efficacy of particular spine surgeries is still relatively uncertain,” said Eugene Carragee, M.D., an orthopedic surgeon and editor in chief of The Spine Journal. “Studies like these are essential to help spine specialists offer appropriate treatments for their patients.”

The first study, “One-year outcomes of surgical versus nonsurgical treatments for discogenic back pain: A community-based prospective cohort study,” concluded that patients who received surgery for discogenic back pain showed slighter greater improvement at one year compared with a non-operatively-treated group, although the composite success rate for both treatment groups was only fair.

In this study, 495 patients with discogenic back pain were enrolled. Eighty-six patients (17 percent) had surgery within six months of enrollment. Surgery consisted of instrumented fusion (79 percent), disc replacement (12 percent), laminectomy or discectomy (9 percent). Surgical patients reported more severe pain and physical disability at baseline and were more likely to have had prior surgery. Adjusting for baseline differences among groups, surgery showed a limited benefit over nonsurgical treatment of 5.4 points on the modified (23-point) Roland-Morris back disability questionnaire one year after enrollment. Using a composite definition of “success” incorporating 30 percent improvement in the Roland score, 30 percent improvement in pain, no opioid pain medication use, and working (if relevant), the one-year success rate was 33 percent for surgery and 15 percent for nonsurgical treatment. The rate of re-operation was 11 percent in the surgical group; the rate of surgery after treatment designation in the nonsurgical group was 6 percent at 12 months after enrollment.

“The results should be interpreted cautiously because outcomes are short-term, and treatment was not randomly assigned,” study authors advised. “Only 5 percent of nonsurgical patients received cognitive behavior therapy. Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines.”

The authors of the study are Sohail K. Mirza, M.D., MPH, Department of Orthopaedic Surgery and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth in Hanover, N.H.; Richard A. Deyo, M.D., MPH, Department of Family Medicine, the Department of Medicine, the Department of Public Health and Preventive Medicine and the Center for Research in Occupational and Environmental Toxicology Oregon Health and Science University, Portland, Ore.; Patrick J. Heagerty, Ph.D., Department of Biostatistics, University of Washington, Seattle, Wash.; Judith A. Turner, Ph.D., Department of Psychiatry and Behavioral Sciences, University of Washington in Seattle; Brook I. Martin, Ph.D., Department of Orthopaedic Surgery and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth; and Bryan A. Comstock, MS, Department of Biostatistics, University of Washington in Seattle.

The second study, “Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: Long-term follow-up of three randomized controlled trials,” concluded that after an average of 11 years follow-up, there was no difference in patient self-rated outcomes between spine fusion and multidisciplinary cognitive-behavioral and exercise rehabilitation for chronic low back pain (cLBP).

In this landmark study, 473 patients with cLBP of at least one year’s duration and who were all considered candidates for spinal fusion received either surgery or multidisciplinary cognitive-behavioral and exercise rehabilitation. Of the original 473 patients, 261 completed outcomes questionnaires (140 had received instrumented or non-instrumented spinal fusion and stabilization surgery and 121 had received multidisciplinary cognitive-behavioral and exercise rehabilitation). The average follow-up was 11.4 [range 8–15] years after the initial treatment.

The intention-to-treat analysis showed no statistically or clinically significant differences between treatment groups for Oswestry Disability Index (ODI) scores at LTFU (adjusted for baseline ODI, previous surgery, duration of LBP, sex, age, and smoking habit): the mean adjusted treatment effect of fusion was _0.7 points on the 0–100 ODI scale (95 percent confidence interval [CI], -5.5 to 4.2). An as-treated analysis similarly demonstrated no advantage of surgery (treatment effect, -0.8 points on the ODI (95 percent CI, -5.9 to 4.3). The results for the secondary outcomes were largely consistent with those of the ODI, showing no relevant group differences. Secondary outcomes included visual analog scale (VAS) pain intensity, pain frequency, pain medication use, work status, EuroQol VAS for health-related quality of life, satisfaction with care, and global treatment outcome at long-term follow-up.

The study’s authors conclude that, given the increased risks of surgery and the lack of deterioration in non-operative outcomes over time, multidisciplinary cognitive-behavioral and exercise rehabilitation programs should be favored.

The authors of the study are Anne F. Mannion, Ph.D., Department of Research and Development, Spine Center, Zurich, Switzerland; Jens Ivar Brox, M.D., Ph.D., Department of Orthopedics, Oslo University Hospital, Oslo, Norway; and Jeremy C.T. Fairbank, M.D., FRCS, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, the United Kingdom.