Spinal fusion slightly more effective than intensive rehabilitation for chronic low back pain

QuestionsIs spinal fusion more effective than intensive rehabilitation in improving disability, walking tolerance, quality of life and psychological distress for patients with chronic low back pain? How frequently do complications occur with the two treatments?DesignSingle blind multicentre randomised controlled trial with intention to treat analysis.Setting15 UK orthopaedic and rehabilitation centres.Patients349 participants aged 18–55 years, with chronic low back pain lasting at least one year, who were considered candidates for spinal fusion were randomly assigned to either lumbar spine fusion (176 participants of whom 139 received it) or intensive rehabilitation program based on cognitive behavioural therapy principles (173 participants of whom 151 received it).InterventionsThe technique for the spinal stabilisation surgery was left to the surgeon’s discretion. The intensive rehabilitation program consisted of a daily outpatient program of exercise and education five days per week for three continuous weeks.OutcomesOutcomes were measured at baseline, 6, 12, and 24 months. Disability was measured using the Oswestry disability index (range 0–100), walking tolerance with the shuttle walking test, quality of life with the SF-36, and distress with the DRAM. The primary outcomes were disability and walking tolerance at two year follow-up.Results81% of patients were followed up at 2 years. At 2 years the surgery group had slightly greater improvement in disability: group mean and 95% CI = 4.1 (0.1 to 8.1). All other improvements in outcomes were not clinically or statistically significantly different between groups. Intraoperative complications occurred in 19 surgical cases, no complications were noted in the rehabilitation group.ConclusionSpinal fusion is slightly more effective than intensive rehabilitation for improving disability in people with chronic low back pain who are candidates for spinal fusion. Complications occurred in 14% receiving surgery and 0% of those receiving intensive rehabilitation