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Overview of surgical management of chronic low back pain.

The incidence of low back pain is common, with most cases being self-limited, with no persistent or serious sequelae. There is only a small percentage of cases that result in disabling non-specific chronic low back pain, CLBP. The cause of CLBP is poorly understood.
The authors found that there are no clearly defined clinical practice guidelines for surgical intervention in chronic low back pain, in the absence of serious structural disease such as instability, infection, or neoplasm. Structural findings of disc degeneration, annular disruption, and end plate changes are commonly seen in patients with CLBP but are also common in cross-sectional studies of asymptomatic populations.

There are generally two schools of thought on the clinical approach to non-specific CLBP. One is the pain generator approach and the other is the psychosocial/economic approach. Since there is the absence of serious spinal disease in non-specific CLBP, any decision regarding the appropriate use of surgery for CLBP must also consider the psychosocial and economic context of the patient. Studies show that disabling CLBP develops more frequently in patients who have a high level of fear avoidance, psychological distress, disputed compensation claims, involvement in tort-compensation system, or job dissastisfaction.

The authors reviewed available studies involving the three general categories of procedures currently used for the surgical treatment of CLBP in the absence of significant spinal pathology. These included fusion, disc arthroplasty, and dynamic stabilization.

Four randomized controlled trials, RCTs, involving lumbar fusion for degenerative disc disease were reviewed. In one study, fusion had favorable results for only 16 percent of participants compared to six percent in the nonoperative group that received usual care. In the other three studies, there were only small differences noted between the fusion and nonoperative groups. The nonsurgical groups had fewer complications and had better coping strategies, the fusion group in one of the studies had a modest improvement in the Oswestry Disability Index.

While clinical trial studies of disc arthroplasty or replacement showed better outcomes than fusion, long-term studies are not available.

Dynamic stabilization can involve the use of devices such as dynamic or static interspinous spacers, pedicle screw-based or pedicle rod-based posterior dynamic stabilizing systems, and total facet replacement systems. The authors conluded that there is not sufficient clinical evidence available to evaluate the efficacy of dynamic stabilization in the management of CLBP.

The authors concluded that there is currently insufficient evidence to draw any firm conclusions that surgical options for the treatment of CLBP are effective.

References: A.S. Don, E. Carragee. A brief overview of evidence-informed management of chronic low back pain with surgery. The Spine Journal. January/February 2008. Volume 8. Issue 1. Pp. 258-265.

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