(i) Optimizing non-operative care

SummarySurgical treatment of back pain has limited success. It is therefore critical that spinal surgeons (who see most back problems in secondary care) are aware of the results of non-operative treatments.It is now known that most of the predictors of the development of long term distress and disability following an episode of back pain are psychosocial. Factors such as a tendency to low mood, fear avoidance, passivity, and poor sickness absence record, (known as "yellow flags"), all feed into the pain experience and thus should be included in the work up. Detection of multiple factors can inform the surgeon about why the person is in trouble and enable better decision making about the likelihood of a biological intervention being successful.Of the non-operative treatments available, although there is limited evidence for exercise programmes and back schools, many commonly employed approaches such as passive physiotherapy and facet joint injections are of unproved benefit.The treatments with best evidence of effectiveness are intensive interdisciplinary programmes (also known as functional restoration or pain management programmes). These therapies have been shown to be as effective as spinal fusion surgery and should be offered to persons with persistent difficulties before proceeding to fusion surgery.