How effective is spinal surgery in treating back pain?

Evans et al (2022) investigated the role of spinal surgery in the treatment of lumbar back pain and came to the following conclusions:  

• Spinal surgery may have a role in relieving radicular pain and disability resulting from nerve compression, or when back pain is due to cancer, infection or gross instability.
• For all other forms of back pain, there is no clinical data and the wider evidence base for spinal surgery for the treatment of LBP is poor and suggests that it is ineffective.
• Emerging areas of interest include selecting a minority of patients who might benefit from surgery based on spinal alignment and/or nuclear medicine scans, but clinical evidence is not available.
• The number of spinal surgeries for back pain has increased significantly in recent decades, and disproportionately in privately insured patients, so the contribution of industry and third-party providers to this increase needs to be carefully considered.

PhysioNovo Note: Radicular pain is very similar to the symptoms of an already advanced stage of hip osteoarthritis. Spinal surgery can then be considered a symptomatic treatment of an arthritic hip and can in specific cases provide short-term relief. Motor examination of the spine and hip should then lead to a correct diagnosis.

There are only a few randomized studies showing that only some patients with some procedures sometimes do well after surgery. This is of little comfort to the majority of patients who do not do well, suffer complications or have the same or more symptoms after surgery.
Dhillon 2016: Because surgery is often performed on the basis of symptoms and a conclusive pathoanatomic diagnosis is lacking, the outcome is often poor and the risk of inaccuracy is high.  It is therefore crucial to carefully select patients with chronic back pain who might be eligible for back surgery.
Brox et al. 2009: After 2 to 4 years, surgical interventions are no more effective than exercise therapy in about 90% of cases.
Fritzell et al. 2001: In a well-informed and selected group of patients with severe chronic lower back pain, lumbar fusion reduces pain and decreases disability more efficiently than usual non-surgical treatment.
Chou et al. 2009: Surgery for radiating complaints (radiculopathy) with herniated disc and symptomatic spinal stenosis may be beneficial in the short term (2 to 3 months) compared with non-surgical therapy, after long-term follow-ups the benefits become significantly less. For non-radicular back pain with common degenerative changes, vertebral fusion is no more effective than intensive rehabilitation with cognitive behavioral modification for pain reduction and function improvement.
Bogduk and Andersson 2009: The results of well-reported clinical trials show that only a small proportion of patients benefit from spinal surgery. In the absence of evidence for effective spinal surgery, careful selection of patients with chronic lower back pain who could be considered for surgery is crucial.
Machado et al 2015 confirm doubts about the effectiveness of surgical treatment of spinal stenosis.

Literature:

• Evans L, O’Donohoe T, Morokoff A, Drummond K (2022) The role of spinal surgery in the treatment of low back pain. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.
• Fritzell P, Hägg O, Wessberg P, Nordwall A (2001) Swedish Lumbar Spine Study Group 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine. 2001;26:2521–32. doi: 10.1097/00007632-200112010-00002. 
• Machado GC, Ferreira PH, Harris IA, Pinheiro MB,  Koes BW, van Tulder M, Rzewuska M, Maher CG, Ferreira ML (2015) Effectiveness of Surgery for Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis. PLoS One. 2015; 10(3): e0122800. doi: 10.1371/journal.pone.0122800 PMCID: PMC4378944. PMID: 25822730
• Bogduk N, Andersson G (2009) Is spinal surgery effective for back pain? F1000 Med Rep. 2009; 1: 60.  doi: 10.3410/M1-60 PMCID: PMC2948294 PMID: 20948720)
• Brox JI, ystein Nygaard Ø P, Holm I, Keller A, Ingebrigtsen T, Reikerås O (2009) Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis 2010;69:1643–1648. doi:10.1136/ard.2009.108902.
• Dhillon KS (2016) Spinal Fusion for Chronic Low Back Pain: A “Magic Bullet” or Wishful Thinking? Malaysian Orthopaedic Journal 2016 Vol 10 No 1.

Literatur: Evans L, O’Donohoe T, Morokoff A, Drummond K (2022) The role of spinal surgery in the treatment of low back pain. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.