The role of spinal surgery in the treatment of low back pain

Abstract

Summary Low back pain (LBP) is common and a leading cause of disability and lost productivity worldwide. Acute LBP is frequently self‐resolving, but recurrence is common, and a significant proportion of patients will develop chronic pain. This transition is perpetuated by anatomical, biological, psychological and social factors. Chronic LBP should be managed with a holistic biopsychosocial approach of generally non‐surgical measures. Spinal surgery has a role in alleviating radicular pain and disability resulting from neural compression, or where back pain relates to cancer, infection, or gross instability. Spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of LBP is poor and suggests it is ineffective. Emerging areas of interest include selection of a minority of patients who may benefit from surgery based on spinal sagittal alignment and/or nuclear medicine scans, but an evidence base is absent. Spinal surgery for back pain has increased substantially over recent decades, and disproportionately among privately insured patients, thus the contribution of industry and third‐party payers to this increase, and their involvement in published research, requires careful consideration.

Elective spinal surgery in New South Wales adults, 2001–20, by procedure funding type: a cross‐sectional study

“…Degenerative spinal disorders and the associated chronic back and leg pain are common health problems 1,2 . Their prevalence increases with age, 2 and people may choose surgery if non‐surgical management has not provided relief 2‐4 . Although the benefits of spinal decompression and fusion for people with degenerative conditions are debated, 3,4 use of these procedures in high income countries has risen substantially in recent decades, but there are significant variations in their use within and between countries 3,5‐9 .…”

“…Although the benefits of spinal decompression and fusion for people with degenerative conditions are debated, 3,4 use of these procedures in high income countries has risen substantially in recent decades, but there are significant variations in their use within and between countries 3,5‐9 . Factors such as population ageing, overuse of diagnostic imaging, and greater expectations about the outcomes achievable with advanced technology may explain the increase in surgery volumes 3,4 . However, consensus about the indications for spinal surgery is limited, as is high quality evidence regarding its clinical effectiveness 3,10 …”

“…In Australia, the rate of privately funded spinal fusions increased by 167% during 1997–2006 (from 7.7 to 20.5 per 100 000 population), while the publicly funded rate increased by only 2% (from 5.1 to 5.2 per 100 000 population) 9 . During 2012–18, 83% of spine procedures were performed in the private sector (as were about two‐thirds of hip and knee replacement procedures), 3 suggesting that financial considerations are important and that access to surgical interventions may consequently be inequitable 3,4,9 …”

“… 1 , 2 Their prevalence increases with age, 2 and people may choose surgery if non‐surgical management has not provided relief. 2 , 3 , 4 Although the benefits of spinal decompression and fusion for people with degenerative conditions are debated, 3 , 4 use of these procedures in high income countries has risen substantially in recent decades, but there are significant variations in their use within and between countries. 3 , 5 , 6 , 7 , 8 , 9 Factors such as population ageing, overuse of diagnostic imaging, and greater expectations about the outcomes achievable with advanced technology may explain the increase in surgery volumes.…”

Is elective spinal surgery overused in private health care in Australia?

“…So why are some surgeons happy to operate without or with only poor evidence regarding its value? 5 In my experience, many believe they can fix the structural problem (that's logical!) and that they have the skills for performing a technically excellent operation (perhaps true).…”