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Subacute and chronic low back pain: Surgical treatment

Author
Roger Chou, MD
Section Editor
Steven J Atlas, MD, MPH
Deputy Editor
H Nancy Sokol, MD

INTRODUCTION

The long-term outcome of acute low back pain is generally favorable. Rapid improvement in pain and disability and return to work are the norm in the first month [1]. Further improvement generally occurs over three months. However, given how common low back pain is, persistent symptoms affect millions of individuals. Subacute low back pain is commonly defined as back pain lasting between 4 and 12 weeks and chronic low back pain as pain that persists for 12 or more weeks. For those with chronic symptoms, few achieve the complete resolution they seek, but rather treatment focuses on controlling pain and improving activity.

This topic will address indications and outcomes of surgery for patients with subacute and chronic back pain who do not respond to more conservative treatment. Conservative and nonsurgical interventional therapies for patients with subacute and chronic low back pain are discussed separately. (See "Subacute and chronic low back pain: Pharmacologic and noninterventional treatment" and "Subacute and chronic low back pain: Nonsurgical interventional treatment".)

A summary of the multiple interventions for subacute and chronic low back pain discussed in these topics is presented in a set of tables (table 1 and table 2 and table 3 and table 4).

Two related issues, surgical treatment for patients with lumbar stenosis and the initial management of patients with acute low back pain, are also discussed separately. (See "Lumbar spinal stenosis: Treatment and prognosis" and "Treatment of acute low back pain".)

INDICATIONS FOR SPINAL SURGERY

Only a small minority of patients suffering from low back pain ever require surgery. However, rates of surgical procedures are rising in the US, particularly for spinal fusion in patients with nonspecific back pain [2].

                

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Literature review current through: Nov 2016. | This topic last updated: Fri Mar 11 00:00:00 GMT 2016.
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References
Top
  1. Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ 2003; 327:323.
  2. Weinstein JN, Lurie JD, Olson PR, et al. United States' trends and regional variations in lumbar spine surgery: 1992-2003. Spine (Phila Pa 1976) 2006; 31:2707.
  3. Vroomen PC, de Krom MC, Knottnerus JA. Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract 2002; 52:119.
  4. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 1983; 8:131.
  5. Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J 2013; 13:99.
  6. Hägg O, Fritzell P, Ekselius L, et al. Predictors of outcome in fusion surgery for chronic low back pain. A report from the Swedish Lumbar Spine Study. Eur Spine J 2003; 12:22.
  7. Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine (Phila Pa 1976) 2000; 25:2616.
  8. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine (Phila Pa 1976) 1997; 22:427.
  9. Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine (Phila Pa 1976) 2007; 32:816.
  10. Fritzell P, Hägg O, Wessberg P, et al. 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 (Phila Pa 1976) 2001; 26:2521.
  11. Brox JI, Reikerås O, Nygaard Ø, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain 2006; 122:145.
  12. Brox JI, Sørensen R, Friis A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine (Phila Pa 1976) 2003; 28:1913.
  13. Fairbank J, Frost H, Wilson-MacDonald J, et al. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ 2005; 330:1233.
  14. Brox JI, Nygaard ØP, Holm I, et al. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis 2010; 69:1643.
  15. Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976) 2009; 34:1094.
  16. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009; 34:1066.
  17. Schafer J, O'Connor D, Feinglass S, Salive M. Medicare Evidence Development and Coverage Advisory Committee Meeting on lumbar fusion surgery for treatment of chronic back pain from degenerative disc disease. Spine (Phila Pa 1976) 2007; 32:2403.
  18. Ohtori S, Koshi T, Yamashita M, et al. Surgical versus nonsurgical treatment of selected patients with discogenic low back pain: a small-sized randomized trial. Spine (Phila Pa 1976) 2011; 36:347.
  19. Gibson JN, Waddell G. Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine (Phila Pa 1976) 2005; 30:2312.
  20. Cahill KS, Chi JH, Day A, Claus EB. Prevalence, complications, and hospital charges associated with use of bone-morphogenetic proteins in spinal fusion procedures. JAMA 2009; 302:58.
  21. Fu R, Selph S, McDonagh M, et al. Effectiveness and harms of recombinant human bone morphogenetic protein-2 in spine fusion: a systematic review and meta-analysis. Ann Intern Med 2013; 158:890.
  22. Simmonds MC, Brown JV, Heirs MK, et al. Safety and effectiveness of recombinant human bone morphogenetic protein-2 for spinal fusion: a meta-analysis of individual-participant data. Ann Intern Med 2013; 158:877.
  23. Rodgers MA, Brown JV, Heirs MK, et al. Reporting of industry funded study outcome data: comparison of confidential and published data on the safety and effectiveness of rhBMP-2 for spinal fusion. BMJ 2013; 346:f3981.
  24. Turner JA, Ersek M, Herron L, et al. Patient outcomes after lumbar spinal fusions. JAMA 1992; 268:907.
  25. Fritzell P, Hägg O, Nordwall A, Swedish Lumbar Spine Study Group. Complications in lumbar fusion surgery for chronic low back pain: comparison of three surgical techniques used in a prospective randomized study. A report from the Swedish Lumbar Spine Study Group. Eur Spine J 2003; 12:178.
  26. Jacobs WC, van der Gaag NA, Kruyt MC, et al. Total disc replacement for chronic discogenic low back pain: a Cochrane review. Spine (Phila Pa 1976) 2013; 38:24.
  27. Blumenthal S, McAfee PC, Guyer RD, et al. A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes. Spine (Phila Pa 1976) 2005; 30:1565.
  28. Zigler J, Delamarter R, Spivak JM, et al. Results of the prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of the ProDisc-L total disc replacement versus circumferential fusion for the treatment of 1-level degenerative disc disease. Spine (Phila Pa 1976) 2007; 32:1155.
  29. Berg S, Tullberg T, Branth B, et al. Total disc replacement compared to lumbar fusion: a randomised controlled trial with 2-year follow-up. Eur Spine J 2009; 18:1512.
  30. Gornet MF, Burkus JK, Dryer RF, Peloza JH. Lumbar disc arthroplasty with Maverick disc versus stand-alone interbody fusion: a prospective, randomized, controlled, multicenter investigational device exemption trial. Spine (Phila Pa 1976) 2011; 36:E1600.
  31. Moreno P, Boulot J. [Comparative study of short-term results between total artificial disc prosthesis and anterior lumbar interbody fusion]. Rev Chir Orthop Reparatrice Appar Mot 2008; 94:282.
  32. Hellum C, Johnsen LG, Storheim K, et al. Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: two year follow-up of randomised study. BMJ 2011; 342:d2786.
  33. Regan JJ, McAfee PC, Blumenthal SL, et al. Evaluation of surgical volume and the early experience with lumbar total disc replacement as part of the investigational device exemption study of the Charité Artificial Disc. Spine (Phila Pa 1976) 2006; 31:2270.
  34. Maroon JC. Current concepts in minimally invasive discectomy. Neurosurgery 2002; 51:S137.
  35. Arts MP, Brand R, van den Akker ME, et al. Tubular diskectomy vs conventional microdiskectomy for sciatica: a randomized controlled trial. JAMA 2009; 302:149.
  36. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007; 356:2245.
  37. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006; 296:2441.
  38. Deen HG, Fenton DS, Lamer TJ. Minimally invasive procedures for disorders of the lumbar spine. Mayo Clin Proc 2003; 78:1249.
  39. Atlas SJ, Keller RB, Wu YA, et al. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976) 2005; 30:927.
  40. Osterman H, Seitsalo S, Karppinen J, Malmivaara A. Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up. Spine (Phila Pa 1976) 2006; 31:2409.
  41. Birkmeyer NJ, Weinstein JN, Tosteson AN, et al. Design of the Spine Patient outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2002; 27:1361.
  42. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2008; 33:2789.
  43. Lurie JD, Tosteson TD, Tosteson AN, et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976) 2014; 39:3.
  44. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006; 296:2451.
  45. Tosteson AN, Skinner JS, Tosteson TD, et al. The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2008; 33:2108.
  46. Tosteson AN, Tosteson TD, Lurie JD, et al. Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation. Spine (Phila Pa 1976) 2011; 36:2061.
  47. van den Hout WB, Peul WC, Koes BW, et al. Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial. BMJ 2008; 336:1351.
  48. Peul WC, van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 2008; 336:1355.
  49. Henriksen L, Schmidt K, Eskesen V, Jantzen E. A controlled study of microsurgical versus standard lumbar discectomy. Br J Neurosurg 1996; 10:289.
  50. Lagarrigue J, Chaynes P. [Comparative study of disk surgery with or without microscopy. A prospective study of 80 cases]. Neurochirurgie 1994; 40:116.
  51. Katayama Y, Matsuyama Y, Yoshihara H, et al. Comparison of surgical outcomes between macro discectomy and micro discectomy for lumbar disc herniation: a prospective randomized study with surgery performed by the same spine surgeon. J Spinal Disord Tech 2006; 19:344.
  52. Tullberg T, Isacson J, Weidenhielm L. Does microscopic removal of lumbar disc herniation lead to better results than the standard procedure? Results of a one-year randomized study. Spine (Phila Pa 1976) 1993; 18:24.
  53. Rasouli MR, Rahimi-Movaghar V, Shokraneh F, et al. Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev 2014; :CD010328.
  54. Evaniew N, Khan M, Drew B, et al. Minimally invasive versus open surgery for cervical and lumbar discectomy: a systematic review and meta-analysis. CMAJ Open 2014; 2:E295.
  55. Erginousakis D, Filippiadis DK, Malagari A, et al. Comparative prospective randomized study comparing conservative treatment and percutaneous disk decompression for treatment of intervertebral disk herniation. Radiology 2011; 260:487.
  56. Barth M, Weiss C, Thomé C. Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy: part 1: evaluation of clinical outcome. Spine (Phila Pa 1976) 2008; 33:265.
  57. Ostelo RW, de Vet HC, Waddell G, et al. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev 2002; :CD003007.
  58. Erdogmus CB, Resch KL, Sabitzer R, et al. Physiotherapy-based rehabilitation following disc herniation operation: results of a randomized clinical trial. Spine (Phila Pa 1976) 2007; 32:2041.
  59. Sakai T, Sairyo K, Takao S, et al. Incidence of lumbar spondylolysis in the general population in Japan based on multidetector computed tomography scans from two thousand subjects. Spine (Phila Pa 1976) 2009; 34:2346.
  60. Möller H, Hedlund R. Surgery versus conservative management in adult isthmic spondylolisthesis--a prospective randomized study: part 1. Spine (Phila Pa 1976) 2000; 25:1711.
  61. Ekman P, Möller H, Hedlund R. The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study. Spine J 2005; 5:36.
  62. Carragee EJ. Single-level posterolateral arthrodesis, with or without posterior decompression, for the treatment of isthmic spondylolisthesis in adults. A prospective, randomized study. J Bone Joint Surg Am 1997; 79:1175.
  63. Möller H, Hedlund R. Instrumented and noninstrumented posterolateral fusion in adult spondylolisthesis--a prospective randomized study: part 2. Spine (Phila Pa 1976) 2000; 25:1716.
  64. North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery 2005; 56:98.
  65. Kumar K, Taylor RS, Jacques L, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain 2007; 132:179.
  66. Turner JA, Hollingworth W, Comstock BA, Deyo RA. Spinal cord stimulation for failed back surgery syndrome: outcomes in a workers' compensation setting. Pain 2010; 148:14.
  67. Hassenbusch SJ, Portenoy RK, Cousins M, et al. Polyanalgesic Consensus Conference 2003: an update on the management of pain by intraspinal drug delivery-- report of an expert panel. J Pain Symptom Manage 2004; 27:540.