Surgery for back pain

is probably no better than intensive rehab for chronic lower back pain according to a study in the May 28 BMJ. Patients considered good candidates for either spinal fusion surgery or rehab were randomized to one or the other. The patients who had surgery were significantly improved (compared to rehab) on only one measure of disability, others were comprable. My reading of the data is that neither group did that well, with substantial ongoing disability.

A cost-benefit analysis of the same patients showed increased cost in the surgery group, but the authors astutely noted that if many of the patients randomized to rehab go on to have surgery that could drive their total costs sky high, since they would have undergone both treatments.

This area remains controversial and there may be a group of patients for whom surgery is beneficial but, if so, they are hard to define prospectively.

This reminds me of one of my favorite articles, in the NEJM. It compared results of acute lower back pain according who the patient saw: primary care provider, orthopedic surgeon or chiropractor. Outcomes were similar, and good, among all three groups, but costs were much higher for orthopedic surgeons (patients all got MRIs) and chiropractors (patients had to come back multiple times for adjustments). Despite similar outcomes, patient satisfaction was highest with chiropractors! perhaps reinforcing my belief that patients like having practitioners spend time with them.