SURGICAL VERSUS NON-SURGICAL TREATMENT OF CHRONIC LOW BACK PAIN: A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS

Abstract

Background: Chronic low back pain is the most common complaint of the working age population. Controversy exists regarding the benefit of surgical fusion of the spine for the treatment of chronic low back pain. We performed a meta-analysis of randomised controlled trials to investigate the effectiveness of surgical fusion for chronic low back pain compared to non-surgical intervention.

Methods: Several electronic databases (MEDLINE, EMBASE, CINAHL, Science Citation Index and Cochrane registry of clinical trials) were searched from 1966 to October 2005. Two authors independently extracted data on study characteristics and methodological quality and the number of patients with early complications from surgery. The random-effect meta-analysis comparison was based on the mean difference in Oswestry Disability Index (ODI) change from baseline to follow-up of patients undergoing surgical versus non-surgical treatment. Between-study heterogeneity was analyzed by means of I2.

Results: Four studies of 58 articles identified in the search were eligible with a total of 740 patients. One of the studies recruited patients with adult isthmic spondy-lolisthesis, whereas the other studies recruited patients with a history of chronic low back pain of at least 1 year duration. Surgical treatment involved posterolateral fusion with or without instrumentation or flexible stabilisation. Non-surgical treatment involved exercise programs with or without cognitive therapy. The follow-up period ranged from 1 to 2 years. The pooled mean difference in ODI between the surgical and non-surgical groups was statistically in favour of surgery (mean difference of ODI: 3.90; 95% confidence interval: 0.17–7.62; p=0.04; I2=21.4%). Surgical treatment was associated with a 13% pooled rate of early complication (95% confidence interval: 6–20%, I2=66.9%).

Conclusion: Surgical fusion for chronic low back pain favoured an improvement in the ODI compared to non-surgical intervention. This difference in ODI is of minimal clinical importance. Furthermore, surgery was associated with a significant risk of complications. Therefore, the cumulative evidence at present does not support routine surgical fusion for the treatment of chronic low back pain.