title: Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain.
abstract: METHODS
  Systematic review of randomized trials comparing surgical to nonsurgical treatment of discogenic back pain.
  
  
  OBJECTIVE
  Compare research methods and results.
  
  
  BACKGROUND
  Recent reports have increased debate about the role of surgery in the treatment of chronic back pain associated with lumbar disc degeneration. We conducted a systematic review of randomized trials comparing lumbar fusion surgery to nonsurgical treatment of chronic back pain associated with lumbar disc degeneration.
  
  
  METHODS
  A literature search identified 5 randomized trials that compared fusion to nonoperative treatment for chronic low back pain. Excluding 1 trial for spondylolisthesis, we compared study participants, interventions, analyses, and outcomes in 4 trials that focused on nonspecific chronic back.
  
  
  RESULTS
  All trials enrolled similar subjects. One study suggested greater improvement in back-specific disability for fusion compared to unstructured nonoperative care at 2 years, but the trial did not report data according to intent-to-treat principles. Three trials suggested no substantial difference in disability scores at 1-year and 2-years when fusion was compared to a 3-week cognitive-behavior treatment addressing fears about back injury. However, 2 of these trials were underpowered to identify clinically important differences. The third trial had high rates of cross-over (>20% for each treatment) and loss to follow-up (20%); it is unclear how these affected results.
  
  
  CONCLUSIONS
  Surgery may be more efficacious than unstructured nonsurgical care for chronic back pain but may not be more efficacious than structured cognitive-behavior therapy. Methodological limitations of the randomized trials prevent firm conclusions.
authors.affiliation: Center for Cost and Outcomes Research, and Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA 98104-2499, USA. mirza@u.washington.edu
authors.forename: Sohail K
authors.initials: SK
authors.lastname: Mirza
authors.forename: Richard A
authors.initials: RA
authors.lastname: Deyo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001416:Back Pain / Q000523:psychology / Q000628:therapy*; D002908:Chronic Disease; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D004185:Disability Evaluation; D006801:Humans; D007403:Intervertebral Disc / Q000473:pathology / Q000601:surgery*; D008159:Lumbar Vertebrae / Q000601:surgery; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D013122:Spinal Diseases / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods*; D016896:Treatment Outcome