The end of spinal fusion for low back pain?

So is this paper finally the nail in the coffin for spinal fusion surgery for back pain?

My dad had a spinal fusion for back pain when I was a kid. It was the early 80’s and he injured his back putting in a new kitchen. He initially had a laminectomy which failed. Laminectomy is no longer used for back pain.

I remember the ambulance turning up to the house. My mum was heavily pregnant with my little brother. The doctors told him he wouldn’t work again. He wanted a second opinion and was seen by a renowned spinal surgeon in London. He had a spinal fusion. His back pain settled down after the op and he hasn’t looked back. He got back to his job as a police officer and carried on to retirement.

So what’s the deal with spinal fusion surgery? The problem is the underlying premise that the ‘degenerate’ or ‘failed’ level is the cause of the back pain. Things got sticky when we realised that such ‘degenerate’ changes don’t actually correlate particularly well with pain. Take a look at the table below from this study. My Dad would have been in his early 30’s: More that 50% of asymptomatic people in this age group are likely to have degenerate changes to their discs.

So what do we make of this? Certainly mechanical back pain is probably the most common condition we see in our physiotherapy clinic. ‘Mechanical’ pain simply refers to a problem with the moving parts of the back. This could be muscle, ligament or joint. And yes it could be disc also. Ultimately, often we simply don’t know the source of pain. But that doesn’t mean we can’t help. Back pain is rarely serious and usually settles on its own. Physio intervention can involve education and gentle mobilisation and manipulation to help to relieve the initial discomfort and muscle spasm followed by some exercise based rehabilitation to regain confidence and return to full function. Overactive muscles may need to relax, weak muscles may need to be strengthened and tight muscles may need to be stretched. Normally a combined approach is required. It is recommended to stay fit and active to prevent episodes of back pain from re-occurring.

The literature is telling us that spinal fusion surgery may not be overly helpful. And my dad? Well maybe it helped him, maybe it solved his back pain, perhaps the laminectomy destabilised the level, maybe it would have settled on its own with time. Who knows?

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