Skip to main content
Wiley Open Access Collection logoLink to Wiley Open Access Collection
. 2022 Dec 11;218(1):40–45. doi: 10.5694/mja2.51788

The role of spinal surgery in the treatment of low back pain

Lachlan Evans 1, Thomas O’Donohoe 1, Andrew Morokoff 1,2, Katharine Drummond 1,2,
PMCID: PMC10107811  PMID: 36502448

Summary

  • Low back pain (LBP) is common and a leading cause of disability and lost productivity worldwide.

  • Acute LBP is frequently self‐resolving, but recurrence is common, and a significant proportion of patients will develop chronic pain. This transition is perpetuated by anatomical, biological, psychological and social factors.

  • Chronic LBP should be managed with a holistic biopsychosocial approach of generally non‐surgical measures.

  • Spinal surgery has a role in alleviating radicular pain and disability resulting from neural compression, or where back pain relates to cancer, infection, or gross instability.

  • Spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of LBP is poor and suggests it is ineffective. Emerging areas of interest include selection of a minority of patients who may benefit from surgery based on spinal sagittal alignment and/or nuclear medicine scans, but an evidence base is absent.

  • Spinal surgery for back pain has increased substantially over recent decades, and disproportionately among privately insured patients, thus the contribution of industry and third‐party payers to this increase, and their involvement in published research, requires careful consideration.

Keywords: Back pain, Chronic pain, Spinal diseases, Neurosurgery


Low back pain (LBP) is common, increasingly prevalent 1 and the leading cause of lost productivity worldwide. 2 Most LBP is generated by non‐specific degenerative changes affecting the bone and soft tissue of the spine, with congenital and acquired deformity, infection, malignancy and trauma comprising a much smaller cohort. 3 It is estimated to account for $4.8 billion in lost annual individual earnings, $622 million in additional welfare repayments and $2.9 billion in lost gross domestic product in Australia alone. 4 Acute LBP resolves in many patients, 5 but recurrence is common and about 60% will develop chronic pain. 6 This transition is perpetuated by a complex interaction of anatomical, biological, psychological and social factors and, as with other forms of chronic pain, is best addressed with an integrated, comprehensive and multidisciplinary pain management program rather than fragmented care. 7 , 8 , 9 A significant proportion of patients with chronic LBP seek care from their general practitioner and, contrary to the recommendation of several guidelines, 10 , 11 , 12 a little over half of patients in high income countries undergo spinal imaging. 13 , 14 Given the high rates of imaging abnormalities of degenerative spinal disease in both symptomatic and asymptomatic individuals (34.4% of asymptomatic patients in one meta‐analysis), 15 , 16 the findings frequently prompt referral to a spinal surgeon. This may then be associated with increased rates of intervention, resource utilisation, and the potential for adverse outcomes. 17 Surgical intervention for LBP is continuing to increase in Australia and disproportionately in privately insured patients. 18 , 19 , 20 Although spinal surgery has a role in the management of back pain related to significant instability, particularly in the context of cancer, infection or previous surgery, its role in the management of non‐specific LBP remains without an evidence base. The objective of this review was to evaluate the current evidence base for spinal surgery in the treatment of axial LBP and highlight important factors that may influence practice.

Methods and definitions

This narrative review focused on studies of any design involving adult patients (aged ≥ 18 years) with axial pain affecting the region of the lumbar spine. We acknowledge the myriad aetiologies of axial LBP and the corollary that treatment strategies must address the underlying cause and, as such, are similarly diverse. The focus of this review is on patients experiencing axial LBP secondary to non‐specific degenerative changes such as facet arthropathy, disc degeneration and soft tissue abnormalities. Studies on neurogenic claudication or radiculopathy treated with surgery were excluded as were those evaluating patients with significant structural abnormalities such as spondylolisthesis and fractures. Studies reporting spinal cord stimulation, radiofrequency ablation or percutaneous administration of epidural analgesia were also considered beyond the scope of our discussion. We performed an electronic search of the MEDLINE database for articles published from 1 January 1991 to 31 December 2021, without restriction of language. We employed the following search strategy: “lower back pain OR lumbar back pain” AND “surg* OR operati*”. Articles were not excluded based on study design. The study quality was assessed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. 21

The role of spinal surgery for patients with neural compression

Decompressive spine surgery is widely accepted (but with a low evidence base) for the management of conditions associated with neural compression, including refractory radicular leg pain secondary to lumbar disc herniation, 22 , 23 and neurogenic claudication due to spinal canal stenosis. 24 Both conditions are relatively common in clinical practice, with an estimated 10% lifetime incidence of symptomatic lumbar canal stenosis and an annual incidence of lumbar radiculopathy in one American study of 4.96 cases per 1000 patient years. 25 , 26 The goal of this surgery is neural decompression with alleviation of neurogenic pain or deficits and improvement of functional mobility; however, it has been associated with an improvement in axial low back pain as measured by the Visual Analogue Scale (VAS) in almost two‐thirds of patients in uncontrolled studies. 27 Similarly, decompression and stabilisation surgery has been demonstrated to improve pain, function and quality of life among selected patients with spinal metastases, particularly for neural decompression to avoid disability. 28 , 29 , 30 This has prompted the development of a number of scoring tools aimed at predicting those who will benefit from surgery in this context, 31 , 32 and forms the basis of the recommendation for neuroimaging among patients with LBP and red flag symptoms in a number of guidelines (Box 1). 10 , 11 , 12

Box 1. Red flag symptoms that should raise suspicion for significant pathology in patients presenting with axial low back pain 3 .

Symptom Possible aetiology
History of cancer Metastatic spread of malignancy to the spine
Unexplained weight loss Metastatic malignancy or chronic infection
Fever, night sweats and/or rigors Spinal infection such as osteomyelitis, discitis, or epidural abscess
Trauma Fractures
Neurological deficit Any pathology resulting in compression of the spinal cord or nerve roots
Age < 40 years Congenital deformity such as spondylolisthesis or scoliosis, infection and fractures

The role of spinal surgery in degenerative low back pain

The evidence supporting spinal surgery for the treatment of LBP in the absence of neural compression, infection, cancer, or gross instability is sparse and contrasts with the increasing frequency at which this surgery is being performed. 20 Existing literature can be dichotomised into trials comparing surgical intervention (decompression, fusion or other) against non‐operative management and those comparing different surgical strategies or techniques. Previous analyses have denoted these two categories as “indication” and “technique” trials respectively. 33 The majority of studies fall into the latter group, are of poor quality, and generally aim for a non‐inferiority analysis of complications and outcomes of a specific technique, rather than efficacy in the management of LBP. 33 , 34 , 35 There is often significant investment of industry and device manufacturers in such trials, which is well recognised to bias results. 36 , 37 The analysis of these studies does not inform the question of the indication for spinal surgery for LBP and may be misleading, as it assumes the efficacy of both procedures.

We identified five randomised controlled trials (RCTs) comparing spinal surgery and non‐operative measures for the treatment of degenerative LBP (Box 2). All were published between 2001 and 2011. Of the five studies, two reported statistically significant improvements in LBP with surgical intervention. An RCT from the Swedish Lumbar Spine Study Group found that lumbar fusion improved LBP (quantified by VAS) and three measures of disability (Oswestry Disability Index [ODI], Million Score, and General Function Score) in comparison to standard conservative management (n = 294). 42 The immediate postoperative complication rate was 17%. Furthermore, a Japanese trial also showed a statistically significant improvement in LBP with lumbar fusion (n = 40). 38 However, neither of these studies referenced the minimal clinically important difference (MCID) — a measure describing the threshold change in an outcome that is clinically, rather than just statistically, significant for patients. 43 , 44 The remaining three RCTs found no benefit of spinal surgery for LBP. A trial published in 2005 described a small, statistically significant, improvement with lumbar fusion that did not meet the threshold of MCID (n = 349). 40 The other two RCTs reported on a cohort of Norwegian patients with degenerative LBP (n = 64) and subsequently on an additional group of patients who had undergone previous lumbar microdiscectomy with persistent axial LBP (n = 60). 39 , 41 Neither trial found a statistically or clinically significant benefit with lumbar fusion.

Box 2. Randomised controlled trials of surgery versus non‐operative treatment for low back pain.

Study (year) Number of patients Follow‐up (months) Intervention Result GRADE*
Ohtori 38 (2011) 41 24 Fusion v minimal treatment VAS, JOAS, ODI significantly improved with surgery (P < 0.05) Low
Brox 39 (2006) 60 12 Fusion v cognitive + exercises ODI no significant difference (P = 0.15) Moderate
Fairbank 40 (2005) 349 24 Fusion v intensive rehabilitation ODI reduced 4.1 in favour of surgery (P = 0.045) Moderate
Brox 41 (2003) 64 12 Fusion v cognitive + exercises ODI reduced 2.3 (P = 0.33) Moderate
Fritzell 42 (2003) 294 24 Fusion v physical therapy VAS reduced in surgical group 33% v 7%; ODI 25% v 6% Moderate

GRADE = Grading of Recommendations Assessment, Development and Evaluation; JOAS = Japanese Orthopaedic Association Score; ODI = Oswestry Disability Index; VAS = Visual Analogue Scale.

*

Low: the true effect might be markedly different from the estimated effect. Moderate: the authors believe that the true effect is probably close to the estimated effect.

Despite adequate randomisation, the above trials are at substantial risk of bias given the lack of patient, surgeon and assessor blinding. Additionally, previous well designed studies have shown the placebo effect of surgical interventions to be significant, and given the propensity for LBP to wax and wane, very long term follow‐up is necessary. 45 Using the GRADE system, a standardised criterion against which the quality and risk of bias in an individual study can be evaluated, all five RCTs consist of low to moderate levels of evidence (Box 3). 21

Box 3. Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria analysis of the five key randomised trials.

Study (year) Risk of bias* Inconsistency Indirectness Imprecision Publication bias Quality*
Ohtori 38 (2011) Moderate None None Minor None Low
Brox 39 (2006) Minor None None None None Moderate
Fairbank 40 (2005) Minor None None None None Moderate
Brox 41 (2003) Minor None None None None Moderate
Fritzell 42 (2003) Minor None None None None Moderate
*

Low: the true effect might be markedly different from the estimated effect. Moderate: the authors believe that the true effect is probably close to the estimated effect.

These findings have been synthesised in numerous systematic reviews and augmented by long term follow‐up data from the three major RCTs examining cohorts from the United Kingdom, Norway and Sweden. 46 , 47 , 48 A systematic review included studies evaluating the treatment of LBP only and pooled data from the above five RCTs (n = 707), comparing patients undergoing lumbar fusion (n = 523) with those managed conservatively (n = 134). 49 After a meta‐analysis, a non‐significant reduction in the ODI of ‐7.39 points was reported (95% CI, ‐20.26 to 5.47; P = 0.26). 49 Postoperative complications were identified in 9–18% of patients undergoing lumbar fusion. 49 Several reviews have broadly examined the role of spinal surgery in degenerative lumbar spine disease, including LBP, radiculopathy and spinal stenosis. 48 , 50 , 51 One such review provided the basis for the 2009 American Pain Society guidelines on the use of spinal surgery in degenerative lumbar spine disease. 50 Consistent with the individual studies described above, the authors found that lumbar fusion was no better than intensive rehabilitation and cognitive behavioural therapy for the treatment of LBP. However, based on data published in 2001, 42 they concluded that lumbar fusion is slightly superior to standard, non‐intensive conservative management. Of note, the authors of the study found that less than half of patients reported an optimal outcome (no more than sporadic pain, slight functional restriction, or occasional analgesic use) after lumbar fusion. 50

Limitations of the spinal surgery literature

A key factor limiting the comparison between trials is the significant difference between the type and intensity of non‐operative management. In trials reporting comparable results between the two groups, non‐operative patients underwent intensive physical rehabilitation as well as cognitive behavioural therapy. 39 , 40 , 41 In comparison, the conservative arms of two studies undertook standard, non‐intensive treatment. 38 , 42 The risk of negative motivation bias in these latter two studies is substantial. Most of the participants had been undertaking standard physiotherapy and pain management for many years and, when assigned to the study arm continuing this previously ineffective treatment (which occurred in a 1:3 ratio compared with the fusion arm), the perception of a poor outcome is likely to be amplified. As such, the benefit of surgical intervention will be exaggerated. However, specialised physical and psychological therapy provided to patients in the British and Norwegian trials may not be available in all health care settings.

Long term follow‐up data have reinforced the initial findings from the British and Norwegian cohorts as well as several meta‐analyses combining the five available RCTs. After an average follow‐up of 11 years, combined data from three studies 39 , 40 , 41 demonstrated no difference in outcome between patients managed conservatively versus those managed with lumbar fusion. 47 Conversely, long term data from the Swedish study reported a statistically significant improvement in the Global Assessment metric for patients undergoing lumbar fusion when analysed on a per protocol basis. 46 That is, only data from patients who completed the treatment to which they were initially randomly allocated were included. The risk of bias using this type of analysis is well recognised. 52 , 53 Based on this single outcome, the authors concluded that lumbar fusion is a viable treatment option for LBP. However, this assertion has attracted robust criticism. 54 The authors provided long term data on several other outcome measures, including the ODI, visual analogue pain scale, work status and ongoing analgesic requirement, all of which demonstrated no difference between the two study groups. 46 In addition, when analysed on an intention‐to‐treat basis there was no difference in the Global Assessment score between conservative and surgical management. 46 As such, clinicians should interpret the results of this latter study with caution. The difficulties with obtaining accurate, objective and reproducible outcome data for patients with chronic pain are highlighted by the controversial long term results reported by the Swedish group.

The small number of aforementioned studies are fundamental to understanding if spinal surgery (in any form) is superior to best conservative management for the treatment of degenerative LBP. Despite their importance, they comprise only a minority of the literature on this topic. 33 Instead, the literature is dominated by small, industry‐supported RCTs that compare one specific surgical technique with another, with the implicit assumption that both are superior to non‐operative management. Describing this body of literature is beyond the scope of this review. However, it must again be emphasised that their objective is not to substantiate the benefit of surgery. Rather, they aim to compare surgical nuances and thus have no value to guide the appropriateness of specialist referral or spinal surgery for patients with LBP, but the effect of the assumption that surgery is effective implicit in such literature is likely to be substantial. Analysing the relevant literature from 1993 to 2012, a 2013 study reported that 33 of 39 identified RCTs assessed technique rather than indication, which was assumed. 33 Furthermore, this article underscored the bias introduced by selective citation of previous positive trials. Evaluating the number of citations of the three key RCTs over a 24‐month period in 2010–2011, they found that surgeon authors disproportionately referenced the Swedish study 42 that supported the use of spinal surgery (134 citations). 33 In comparison, the two negative trials 39 , 40 received far fewer citations (54 and 51 respectively). 33 There was no significant difference in citation frequency by non‐surgeon authors.

There is a clear lack of evidence supporting the use of spinal surgery for the treatment of LBP. Importantly, the currently available studies up to 2011 do not address much that has changed over the past 10 years in spinal surgery. Minimally invasive fusion techniques, improved implant materials, and a better understanding of sagittal alignment have yet to be rigorously tested in high quality randomised trials and, hence, their impact on the efficacy of spinal surgery remains unknown. The difficulties with successfully conducting unbiased randomised trials of spinal surgery have been detailed above. Transparent multicentre trials independent from industry are fundamental to more adequately establish the benefit of modern surgical techniques and move beyond this impasse. Consistent with previous trials in the spinal 55 and non‐spinal 56 , 57 , 58 literature, these trials should be independent from industry and be supported by philanthropic and governmental research funding agencies. In a similar vein, the methodological flaws and systemic biases present within the existing literature must be acknowledged.

Emerging areas of interest

The substantial heterogeneity in the biological, psychological and social circumstances of patients with LBP may have contributed to the failure of previous trials. Thus, there may be unidentified subgroups of patients with LBP who would benefit from surgery. This would rely on identification of reliable investigations to identify surgical candidates. There is some evidence for the use of lumbar discography to identify discs generating pain, but this technique remains controversial and is invasive. 59 There has also been significant interest in the role of single‐photon emission computed tomography (SPECT) with computed tomography (CT) to assess inflammation of discs and facet joints that could be pain generators. 60 However, as for magnetic resonance imaging evidence of degenerative disease, SPECT‐CT abnormalities are common in healthy pain‐free controls, 60 and a Korean study observed no significant difference between patients receiving targeted pain interventions who did (n = 110, 73.83%) and did not (n = 17, 65.38%) have changes on SPECT‐CT (P = 0.37). 61 Over the past three decades, there has also been growing interest in the relationship between the sagittal alignment of the spine and LBP. 62 , 63 This has prompted some surgeons to routinely obtain standing lateral and antero‐posterior x‐rays to measure sagittal alignment. However, there is significant variability in spinal and pelvic alignment in healthy controls, 64 , 65 which creates difficulty in specifically defining pathological sagittal imbalance. Moreover, although it has garnered increasing support as an outcome measure among patients undergoing deformity correction procedures, 66 changes in sagittal alignment are commonly observed with age, 67 and the role of surgical restoration of physiological parameters for the treatment of LBP remains investigative. For these reasons, routine imaging of patients with LBP with SPECT‐CT or standing x‐rays is not recommended in any of the major international LBP guidelines. 10 , 11 , 12 These imaging modalities may be appropriate adjunctive investigations among patients in whom a decision has already been made to operate.

Lumbar disc arthroplasty, in which a diseased intervertebral disc is removed entirely and replaced with an artificial disc, has been expounded as a motion‐preserving treatment for discogenic LBP. 68 However, no high quality RCTs have found a clinically significant benefit in comparison to lumbar fusion or non‐operative management. 69 , 70 , 71 Again, the literature is thus far dominated by technique trials assessing different types of artificial discs as well as small non‐inferiority studies comparing arthroplasty with lumbar fusion. 70 , 72

Finally, in light of the increased incidence of LBP in obese patients, 73 there has been increasing attention and reports of LBP improvement in patients achieving weight loss after bariatric surgery. 74 , 75 However, these data are derived from a small number of uncontrolled studies, and whether bariatric surgery is superior to a holistic program of non‐operative interventions for the treatment of LBP among obese patients remains conjectural.

Industry influence

Given the increasing frequency and complexity of spinal surgery, 20 it is essential to consider the cost to the health care system, with spinal fusions being recently estimated to cost $46 288 ± $22 112 per episode in Australia. 76 It is also essential to consider the role of industry and device manufacturers. The exponential growth of spinal fusion, particularly in the private sector, has driven (and is likely been driven by) a concomitant increase in the development of new implants and instrumentation techniques. 20 , 76 The detrimental association between industry and research is well documented across the medical literature and may, in part, explain the predominance of technique trials detailed previously. 77 A 2017 analysis of nearly 6000 North American spine surgeons found that 91.6% reported at least one financial relationship with industry. 78 Such associations are common across modern health care, but the central role of implants and instrumentation in many contemporary spinal operations heightens the risk of industry influence. 79 Furthermore, while financial association alone does not prove that an individual surgeon's practice has been unduly altered, the impact of financial support on guideline formation, clinical decision making, and prescribing is well documented in other areas of medicine. 80 , 81 , 82 A review of articles published from 2002 to 2003 found that 15.9% reported industry funding (57.9% of articles did not disclose a funding source). 83 The same study noted industry‐funded trials were 3.3 times more likely to report a positive outcome compared with other trials (P < 0.001). 83 Despite the above, surgeons consistently state that they do not consider this relationship a significant determinant of their practice. 84 The authors recognise the many benefits that transparent cooperation between clinicians and industry can have in supporting research and development as well as financing large‐scale, randomised trials that would otherwise be difficult to complete in the public health care system. However, given the rapid and lucrative expansion of instrumented spinal fusion for both LBP and neural decompression, the influence of this interplay on research quality and ethics, public health policy, and individual patient outcomes warrant careful consideration. The use of spinal surgery for the treatment of LBP is an important example of the complex intersection between a poor evidence base, industry involvement, and a demanding patient population.

Conclusion

The increasing burden of LBP presents a significant challenge to health care systems throughout the world. Its management should be overseen by primary care physicians and centred upon a holistic biopsychosocial approach of generally non‐surgical interventions. Even though spinal surgery does have a role in alleviating symptoms of radiculopathy or neurogenic claudication, or in circumstances where back pain is related to cancer, infection or gross instability, its role in the management of degenerative LBP is not supported by the studies currently available. Despite this, surgical intervention for LBP has increased substantially among Australian patients, and disproportionately among those with private health insurance. The contribution of industry toward this increase, and their role in the conduct of published research, requires further scrutiny.

Open access

Open access publishing facilitated by The University of Melbourne, as part of the Wiley – The University of Melbourne agreement via the Council of Australian University Librarians.

Competing interests

No relevant disclosures.

Provenance

Commissioned; externally peer reviewed.

References

  • 1. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012; 64: 2028‐2037. [DOI] [PubMed] [Google Scholar]
  • 2. Wu A, March L, Zheng X, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med 2020; 8: 299. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3. Vlaeyen JWS, Maher CG, Wiech K, et al. Low back pain. Nat Rev Dis Primers 2018; 4: 52. [DOI] [PubMed] [Google Scholar]
  • 4. Schofield DJ, Shrestha RN, Percival R, et al. The personal and national costs of early retirement because of spinal disorders: impacts on income, taxes, and government support payments. Spine J 2012; 12: 1111‐1118. [DOI] [PubMed] [Google Scholar]
  • 5. Menezes Costa L, Maher CG, Hancock MJ, et al. The prognosis of acute and persistent low‐back pain: a meta‐analysis. CMAJ 2012; 184: E613‐E624. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. Costa Lda C, Maher CG, McAuley JH, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ 2009; 339: b3829. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Gibson CJ, Grasso J, Li Y, et al. An integrated pain team model: impact on pain‐related outcomes and opioid misuse in patients with chronic pain. Pain Med 2020; 21: 1977‐1984. [DOI] [PubMed] [Google Scholar]
  • 8. Purcell N, Zamora K, Tighe J, et al. The integrated pain team: a mixed‐methods evaluation of the impact of an embedded interdisciplinary pain care intervention on primary care team satisfaction, confidence, and perceptions of care effectiveness. Pain Med 2018; 19: 1748‐1763. [DOI] [PubMed] [Google Scholar]
  • 9. Tien JJN, Tan HC, Chua CT, et al. Implementing an evidence‐based structured education and management program in an inpatient adult oncology setting to improve patients’ pain control. JBI Evid Implement 2022; 10.1097/XEB.0000000000000309 [Epub ahead of print]. [DOI] [PubMed] [Google Scholar]
  • 10. Bernstein IA, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of NICE guidance. BMJ 2017; 356: i6748. [DOI] [PubMed] [Google Scholar]
  • 11. Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non‐specific low back pain in primary care: an updated overview. Eur Spine J 2018; 27: 2791‐2803. [DOI] [PubMed] [Google Scholar]
  • 12. Almeida M, Saragiotto B, Richards B, Maher CG. Primary care management of non‐specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208: 272‐275. https://www.mja.com.au/journal/2018/208/6/primary‐care‐management‐non‐specific‐low‐back‐pain‐key‐messages‐recent‐clinical [DOI] [PubMed] [Google Scholar]
  • 13. Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med 2015; 175: 1913‐1920. [DOI] [PubMed] [Google Scholar]
  • 14. Rizzardo A, Miceli L, Bednarova R, et al. Low‐back pain at the emergency department: still not being managed? Ther Clin Risk Manag 2016; 12: 183‐187. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. Kalichman L, Cole R, Kim DH, et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J 2009; 9: 545‐550. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16. Brinjikji W, Diehn FE, Jarvik JG, et al. MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: a systematic review and meta‐analysis. AJNR Am J Neuroradiol 2015; 36: 2394‐2399. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. Bederman SS, Kreder HJ, Weller I, et al. The who, what and when of surgery for the degenerative lumbar spine: a population‐based study of surgeon factors, surgical procedures, recent trends and reoperation rates. Can J Surg 2009; 52: 283‐290. [PMC free article] [PubMed] [Google Scholar]
  • 18. Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain. Radiol Clin North Am 2012; 50: 569‐585. [DOI] [PubMed] [Google Scholar]
  • 19. Yamaguchi JT, Weiss HK, Garcia RM, et al. Trends in national utilization of posterior lumbar fusion and 30‐day reoperation and readmission rates from 2006–2016. Clin Neurol Neurosurg 2020; 199: 106310. [DOI] [PubMed] [Google Scholar]
  • 20. Harris IA, Dao AT. Trends of spinal fusion surgery in Australia: 1997 to 2006. ANZ J Surg 2009; 79: 783‐788. [DOI] [PubMed] [Google Scholar]
  • 21. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924‐926. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22. Bailey CS, Rasoulinejad P, Taylor D, et al. Surgery versus conservative care for persistent sciatica lasting 4 to 12 months. N Engl J Med 2020; 382: 1093‐1102. [DOI] [PubMed] [Google Scholar]
  • 23. Wilby MJ, Best A, Wood E, et al. Surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica secondary to herniated lumbar disc (NERVES): a phase 3, multicentre, open‐label, randomised controlled trial and economic evaluation. Lancet Rheumatol 2021; 3: e347‐e356. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24. Ma XL, Zhao XW, Ma JX, et al. Effectiveness of surgery versus conservative treatment for lumbar spinal stenosis: A system review and meta‐analysis of randomized controlled trials. Int J Surg 2017; 44: 329‐338. [DOI] [PubMed] [Google Scholar]
  • 25. Schoenfeld AJ, Laughlin M, Bader JO, Bono CM. Characterization of the incidence and risk factors for the development of lumbar radiculopathy. J Spinal Disord Tech 2012; 25: 163‐167. [DOI] [PubMed] [Google Scholar]
  • 26. Ishimoto Y, Yoshimura N, Muraki S, et al. Prevalence of symptomatic lumbar spinal stenosis and its association with physical performance in a population‐based cohort in Japan: the Wakayama Spine Study. Osteoarthritis Cartilage 2012; 20: 1103‐1108. [DOI] [PubMed] [Google Scholar]
  • 27. Iorio‐Morin C, Fisher CG, Abraham E, et al. Low‐back pain after lumbar discectomy for disc herniation: what can you tell your patient? J Neurosurg Spine 2021; 35: 715‐721. [DOI] [PubMed] [Google Scholar]
  • 28. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366: 643‐648. [DOI] [PubMed] [Google Scholar]
  • 29. Choi D, Fox Z, Albert T, et al. Prediction of quality of life and survival after surgery for symptomatic spinal metastases: a multicenter cohort study to determine suitability for surgical treatment. Neurosurgery 2015; 77: 698‐708; discussion 708. [DOI] [PubMed] [Google Scholar]
  • 30. Fehlings MG, Nater A, Tetreault L, et al. Survival and clinical outcomes in surgically treated patients with metastatic epidural spinal cord compression: results of the prospective multicenter AOSpine study. J Clin Oncol 2016; 34: 268‐276. [DOI] [PubMed] [Google Scholar]
  • 31. Laufer I, Rubin DG, Lis E, et al. The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist 2013; 18: 744‐751. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32. Fisher CG, DiPaola CP, Ryken TC, et al. A novel classification system for spinal instability in neoplastic disease: an evidence‐based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976) 2010; 35: E1221‐E1229. [DOI] [PubMed] [Google Scholar]
  • 33. Andrade NS, Flynn JP, Bartanusz V. Twenty‐year perspective of randomized controlled trials for surgery of chronic nonspecific low back pain: citation bias and tangential knowledge. Spine J 2013; 13: 1698‐1704. [DOI] [PubMed] [Google Scholar]
  • 34. Thalgott JS, Fogarty ME, Giuffre JM, et al. A prospective, randomized, blinded, single‐site study to evaluate the clinical and radiographic differences between frozen and freeze‐dried allograft when used as part of a circumferential anterior lumbar interbody fusion procedure. Spine (Phila Pa 1976) 2009; 34: 1251‐1256. [DOI] [PubMed] [Google Scholar]
  • 35. Xue H, Tu Y, Cai M. Comparison of unilateral versus bilateral instrumented transforaminal lumbar interbody fusion in degenerative lumbar diseases. Spine J 2012; 12: 209‐215. [DOI] [PubMed] [Google Scholar]
  • 36. Wang HL, Lu FZ, Jiang JY, et al. Minimally invasive lumbar interbody fusion via MAST Quadrant retractor versus open surgery: a prospective randomized clinical trial. Chin Med J (Engl) 2011; 124: 3868‐3874. [PubMed] [Google Scholar]
  • 37. Bhandari M, Busse J, Jackowski D, et al. Association between industry funding and statistically significant pro‐industry findings in medical and surgical randomized trials. CMAJ 2004; 170: 477‐480. [PMC free article] [PubMed] [Google Scholar]
  • 38. 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: 347‐354. [DOI] [PubMed] [Google Scholar]
  • 39. Brox JI, Reikeras O, Nygaard O, 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: 145‐155. [DOI] [PubMed] [Google Scholar]
  • 40. 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. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41. Brox JI, Sorensen 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: 1913‐1921. [DOI] [PubMed] [Google Scholar]
  • 42. Fritzell P, Hagg 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: 2521‐2532; discussion 2532‐2524. [DOI] [PubMed] [Google Scholar]
  • 43. Copay AG, Glassman SD, Subach BR, et al. Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J 2008; 8: 968‐974. [DOI] [PubMed] [Google Scholar]
  • 44. Bombardier C, Hayden J, Beaton DE. Minimal clinically important difference. Low back pain: outcome measures. J Rheumatol 2001; 28: 431‐438. [PubMed] [Google Scholar]
  • 45. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347: 81‐88. [DOI] [PubMed] [Google Scholar]
  • 46. Hedlund R, Johansson C, Hägg O, et al. The long‐term outcome of lumbar fusion in the Swedish lumbar spine study. Spine J 2016; 16: 579‐587. [DOI] [PubMed] [Google Scholar]
  • 47. Mannion AF, Brox JI, Fairbank JC. Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long‐term follow‐up of three randomized controlled trials. Spine J 2013; 13: 1438‐1448. [DOI] [PubMed] [Google Scholar]
  • 48. Harris IA, Traeger A, Stanford R, et al. Lumbar spine fusion: what is the evidence? Intern Med J 2018; 48: 1430‐1434. [DOI] [PubMed] [Google Scholar]
  • 49. Bydon M, De la Garza‐Ramos R, Macki M, et al. Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta‐analysis of randomized controlled trials. J Spinal Disord Tech 2014; 27: 297‐304. [DOI] [PubMed] [Google Scholar]
  • 50. 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: 1094‐1109. [DOI] [PubMed] [Google Scholar]
  • 51. Jacobs WC, Rubinstein SM, Willems PC, et al. The evidence on surgical interventions for low back disorders, an overview of systematic reviews. Eur Spine J 2013; 22: 1936‐1949. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52. McCoy CE. Understanding the Intention‐to‐treat principle in randomized controlled trials. West J Emerg Med 2017; 18: 1075‐1078. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53. Ranganathan P, Pramesh CS, Aggarwal R. Common pitfalls in statistical analysis: Intention‐to‐treat versus per‐protocol analysis. Perspect Clin Res 2016; 7: 144‐146. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54. Mannion AF, Brox J. and Fairbank, J . Consensus at last! Long‐term results of all randomized controlled trials show that fusion is no better than non‐operative care in improving pain and disability in chronic low back pain. Spine J 2016; 16: 588‐590. [DOI] [PubMed] [Google Scholar]
  • 55. Austevoll IM, Hermansen E, Fagerland MW, et al. Decompression with or without fusion in degenerative lumbar spondylolisthesis. N Engl J Med 2021; 385: 526‐538. [DOI] [PubMed] [Google Scholar]
  • 56. Goldstone AB, Chiu P, Baiocchi M, et al. Mechanical or biologic prostheses for aortic‐valve and mitral‐valve replacement. N Engl J Med 2017; 377: 1847‐1857. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 57. Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med 2015; 373: 1597‐1606. [DOI] [PubMed] [Google Scholar]
  • 58. Abdel‐Fattah M, Cooper D, Davidson T, et al. Single‐incision mini‐slings for stress urinary incontinence in women. N Engl J Med 2022; 386: 1230‐1243. [DOI] [PubMed] [Google Scholar]
  • 59. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence‐based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician 2013; 16 (Suppl): S49‐S283. [PubMed] [Google Scholar]
  • 60. Van de Kelft E, Verleye G, Van de Kelft AS, et al. Validation of topographic hybrid single‐photon emission computerized tomography with computerized tomography scan in patients with and without nonspecific chronic low back pain. A prospective comparative study. Spine J 2017; 17: 1457‐1463. [DOI] [PubMed] [Google Scholar]
  • 61. Lee I, Budiawan H, Moon JY, et al. The value of SPECT/CT in localizing pain site and prediction of treatment response in patients with chronic low back pain. J Korean Med Sci 2014; 29: 1711‐1716. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62. Glassman SD, Berven S, Bridwell K, et al. Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976) 2005; 30: 682‐688. [DOI] [PubMed] [Google Scholar]
  • 63. Jackson RP, McManus AC. Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size. A prospective controlled clinical study. Spine (Phila Pa 1976 ) 1994; 19: 1611‐1618. [DOI] [PubMed] [Google Scholar]
  • 64. Boulay C, Tardieu C, Hecquet J, et al. Sagittal alignment of spine and pelvis regulated by pelvic incidence: standard values and prediction of lordosis. Eur Spine J 2006; 15: 415‐422. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65. Ct Kuntz, Levin LS, Ondra SL, et al. Neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults: a review and resynthesis of the literature. J Neurosurg Spine 2007; 6: 104‐112. [DOI] [PubMed] [Google Scholar]
  • 66. Glassman SD, Bridwell K, Dimar JR, et al. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 2005; 30: 2024‐2029. [DOI] [PubMed] [Google Scholar]
  • 67. Lee ES, Ko CW, Suh SW, et al. The effect of age on sagittal plane profile of the lumbar spine according to standing, supine, and various sitting positions. J Orthop Surg Res 2014; 9: 11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68. Jacobs W, Van der Gaag NA, Tuschel A, et al. Total disc replacement for chronic back pain in the presence of disc degeneration. Cochrane Database Syst Rev 2012; (9): CD008326. [DOI] [PubMed] [Google Scholar]
  • 69. 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. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 70. Ding F, Jia Z, Zhao Z, et al. Total disc replacement versus fusion for lumbar degenerative disc disease: a systematic review of overlapping meta‐analyses. Eur Spine J 2017; 26: 806‐815. [DOI] [PubMed] [Google Scholar]
  • 71. Salzmann SN, Plais N, Shue J, Girardi FP. Lumbar disc replacement surgery‐successes and obstacles to widespread adoption. Curr Rev Musculoskelet Med 2017; 10: 153‐159. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 72. Yue JJ, Garcia R, Blumenthal S, et al. Five‐year results of a randomized controlled trial for lumbar artificial discs in single‐level degenerative disc disease. Spine (Phila Pa 1976) 2019; 44: 1685‐1696. [DOI] [PubMed] [Google Scholar]
  • 73. Chou L, Brady SRE, Urquhart DM, et al. The association between obesity and low back pain and disability is affected by mood disorders: a population‐based, cross‐sectional study of men. Medicine (Baltimore) 2016; 95: e3367‐e3367. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 74. Joaquim AF, Helvie P, Patel AA. Bariatric surgery and low back pain: a systematic literature review. Global Spine J 2020; 10: 102‐110. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 75. Koremans FW, Chen X, Das A, Diwan AD. Changes in back pain scores after bariatric surgery in obese patients: a systematic review and meta‐analysis. J Clin Med 2021; 10: 1443. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 76. Lewin AM, Fearnside M, Kuru R, et al. Rates, costs, return to work and reoperation following spinal surgery in a workers’ compensation cohort in New South Wales, 2010–2018: a cohort study using administrative data. BMC Health Serv Res 2021; 21: 955. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 77. Fisher MA. Medicine and industry: a necessary but conflicted relationship. Perspect Biol Med 2007; 50: 1‐6. [DOI] [PubMed] [Google Scholar]
  • 78. Weiner JA, Cook RW, Hashmi S, et al. Factors associated with financial relationships between spine surgeons and industry: an analysis of the open payments database. Spine (Phila Pa 1976) 2017; 42: 1412‐1418. [DOI] [PubMed] [Google Scholar]
  • 79. Errico T. The promethean role of industry in spine surgery research. J Spinal Disord Tech 2010; 23: 491‐492. [DOI] [PubMed] [Google Scholar]
  • 80. Mitchell AP, Mishra A, Dey P, et al. Personal payments from pharmaceutical companies to authors of oncology clinical practice guidelines. Oncologist 2021; 26: e1897. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 81. Fickweiler F, Fickweiler W, Urbach E. Interactions between physicians and the pharmaceutical industry generally and sales representatives specifically and their association with physicians’ attitudes and prescribing habits: a systematic review. BMJ Open 2017; 7: e016408. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 82. Trayer J, Rowbotham N, Boyle R, Smyth A. Industry influence in healthcare harms patients: myth or maxim? Breathe. 2022; 18: 220010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 83. Shah RV, Albert TJ, Bruegel‐Sanchez V, et al. Industry support and correlation to study outcome for papers published in Spine . Spine (Phila Pa 1976) 2005; 30: 1099‐1104; discussion 1105. [DOI] [PubMed] [Google Scholar]
  • 84. DiPaola CP, Dea N, Dvorak MF, et al. Surgeon‐industry conflict of interest: survey of opinions regarding industry‐sponsored educational events and surgeon teaching: clinical article. J Neurosurg Spine 2014; 20: 313‐321. [DOI] [PubMed] [Google Scholar]

Articles from The Medical Journal of Australia are provided here courtesy of Wiley

RESOURCES