(ii) The role of surgery in low back pain

SummarySpinal fusion for low back pain (LBP) in the absence of serious underlying disease is controversial. The cause of serious LBP illness is not well understood, there is poor correlation of the presence and degree of degenerative changes with symptoms and non-structural factors such as central pain intolerance, psychological distress, social and economic issues of compensation and participation, appear to act as co-morbidities to LBP illness. Fusion surgery appears to offer only limited relative benefits over cognitive behavioural therapy and intensive rehabilitation in RCTs of surgical vs. non-operative care. At best, possibly 50% of fusion patients in this setting have high-quality outcomes. Artificial disc replacement has approximately the same outcomes as fusion in short-term studies but the long-term risks of prosthesis placement in relatively young patients is a concern. Future surgical advances may be limited by a lack of clear diagnostic certainty and the high prevalence of serious co-morbidities that impair recovery.