Dr. Hiro K

Video 04

Spinal fusion for back pain: why this spine surgeon rarely does it

For back pain alone, two questions usually have no answer: which level is causing the pain, and will it last? What the fusion trials found, when I would consider it, and what I do instead.

In short

  • Worn discs on MRI are common without any back pain: about a third at 20, almost everyone by 80.
  • Against a structured exercise and coaching program, fusion for back pain alone was no better, and the same at about 11 years.
  • Exceptions: a slipped vertebra, or one level that clearly hinges open when you bend.
  • In my own patients, about 8 in 10 improved with a stimulator and about 6 in 10 would recommend it. These are real-world clinic data, not a trial. Aim for half the pain, not zero.
  • Ask: how do you know this is the level, could it settle on its own, and have I done a structured program first?

Summary

To fuse a painful level, you first have to know which level is painful. Worn discs on MRI are found in most people with no back pain at all, and the disc injection test that tries to find the culprit is often painful in people without a back-pain problem. When surgeons fused the disc the test pointed to, only about a quarter had a truly good result.

The second question is whether the problem is permanent. MRI changes around a disc can settle, and back pain itself often improves over months. A fusion is permanent, and a permanent fix for a temporary problem is a bad trade.

In the trials, fusion beat ordinary physical therapy, but against a structured program of exercise and coaching it was no better, and about eleven years later the two groups ended up in the same place. I would consider fusion for a slipped vertebra or one clearly unstable level. For most people with back pain alone I start with a structured program, and if severe pain continues, newer spinal cord stimulation is another option that can be tried before anything permanent.

Sources

  1. In people with no back pain at all, worn discs on MRI were found in about a third of 20-year-olds and in almost everyone by age 80.

    Review of 33 studies, 3,110 people without symptoms. Disc degeneration: 37% at age 20, 96% at age 80. Disc bulges: 30% to 84%.

    Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. PubMed 25430861 · DOI

  2. The disc injection test was painful in about one in four people who did not have a chronic back-pain problem.

    69 volunteers without significant low back pain: at least one painful low-pressure injection in 17 (25%). In 52 patients with chronic back pain: 27%.

    Carragee EJ, Alamin TF, Carragee JM. Low-pressure positive discography in subjects asymptomatic of significant low back pain illness. Spine (Phila Pa 1976). 2006;31(5):505-509. PubMed 16508542 · DOI

  3. When surgeons fused the one disc the injection test pointed to, only about a quarter had a truly good result, against nearly three in four of people fused for a slipped vertebra.

    32 patients fused after a positive single-level test vs 34 matched patients with an unstable slipped vertebra. Highly effective result: 27% vs 72%.

    Carragee EJ, Lincoln T, Parmar VS, Alamin T. A gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine (Phila Pa 1976). 2006;31(18):2115-2123. PubMed 16915099 · DOI

  4. Ten years after the injection test, the discs that had been needled had worn faster than discs that had not.

    50 people tested vs 52 matched controls, followed 7 to 10 years. Progression of disc degeneration: 35% vs 14%. New disc herniations: 55 vs 22.

    Carragee EJ, Don AS, Hurwitz EL, et al. 2009 ISSLS Prize Winner: Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine (Phila Pa 1976). 2009;34(21):2338-2345. PubMed 19755936 · DOI

  5. Inflamed-looking changes next to a disc on MRI are not fixed: on a later scan about half had settled into a quieter pattern.

    44 patients, 48 areas of Modic type 1 change, rescanned after 12 to 72 months. Fully or partly converted to the quieter type 2: 52%. Worse: 40%. A small study.

    Mitra D, Cassar-Pullicino VN, McCall IW. Longitudinal study of vertebral type-1 end-plate changes on MR of the lumbar spine. Eur Radiol. 2004;14(9):1574-1581. PubMed 15060839 · DOI

  6. Back pain that has lasted for weeks improves a lot over the first few months, then more slowly, and some pain often remains at a year.

    33 cohorts, 11,166 people. Persistent back pain, average score out of 100: 51 at the start, 33 at 6 weeks, 26 at 26 weeks, 23 at a year.

    da C Menezes Costa L, Maher CG, Hancock MJ, et al. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012;184(11):E613-E624. PubMed 22586331 · DOI

  7. In a Swedish trial, fusion did better than ordinary physical therapy, but the pain improved most in the first six months and then slowly crept back.

    294 patients with severe back pain for at least 2 years. At 2 years, better or much better: 63% with fusion vs 29% with physical therapy. Back pain down 33% vs 7%.

    Fritzell P, Hägg O, Wessberg P, Nordwall A. 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(23):2521-2532. PubMed 11725230 · DOI

  8. In the same Swedish trial, complications and repeat surgery depended on the fusion technique: up to four in ten had a complication within two years.

    211 fusion patients. Complications at 2 years: 12% (no screws), 22% (screws), 40% (screws plus a front graft). Repeat surgery: 6%, 22%, 17%.

    Fritzell P, Hägg O, Nordwall A. Complications in lumbar fusion surgery for chronic low back pain: comparison of three surgical techniques used in a prospective randomized study. Eur Spine J. 2003;12(2):178-189. PubMed 12709856 · DOI

  9. In a British trial, against a structured exercise and coaching program, fusion was only just better, by a margin that barely counted.

    349 patients. Disability score difference at 2 years: 4.1 points in favour of fusion (95% CI 0.1 to 8.1), only just reaching the minimal clinical difference. No clear evidence fusion was more beneficial.

    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(7502):1233. PubMed 15911537 · DOI

  10. In a Norwegian trial, success after fusion and after exercise with coaching was about the same, slightly higher with the program.

    64 patients with worn discs. Disability 41 to 26 after fusion vs 42 to 30 after the program (no significant difference). Success: 70% vs 76%.

    Brox JI, Sørensen 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(17):1913-1921. PubMed 12973134 · DOI

  11. About 11 years later, people who had fusion and people who did the structured program had ended up in the same place.

    Three trials in Norway and the UK, 261 people followed for an average of 11.4 years. Disability difference: -0.7 points on a 0-100 scale.

    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(11):1438-1448. PubMed 24200413 · DOI

  12. With an older stimulation approach, in people with back pain after surgery, only about one in seven got half their back pain relief.

    218 patients randomized. At least 50% less back pain at 6 months: 13.6% with stimulation plus medical care vs 4.6% with medical care alone. Run with industry involvement (Medtronic), not blinded.

    Rigoard P, Basu S, Desai M, et al. Multicolumn spinal cord stimulation for predominant back pain in failed back surgery syndrome patients: a multicenter randomized controlled trial. Pain. 2019;160(6):1410-1420. PubMed 30720582 · DOI

  13. With newer stimulation, in people with back pain who had never had surgery, about eight in ten of those who received a stimulator got at least half their pain relief.

    159 patients randomized. At least 50% pain relief at 3 months: 80.9% of those who received a stimulator vs 1.3% with usual care. Run with industry involvement, not blinded; the 80.9% counts patients who received an implant.

    Kapural L, Jameson J, Johnson C, et al. Treatment of nonsurgical refractory back pain with high-frequency spinal cord stimulation at 10 kHz: 12-month results of a pragmatic, multicenter, randomized controlled trial. J Neurosurg Spine. 2022;37(2):188-199. PubMed 35148512 · DOI

  14. Two years later, the results of that trial were holding.

    98 implanted patients followed to 24 months. Responders (at least 50% relief): 82%. Device removals: 4.8%.

    Patel NP, Jameson J, Johnson C, et al. Durable responses at 24 months with high-frequency spinal cord stimulation for nonsurgical refractory back pain. J Neurosurg Spine. 2024;40(2):229-239. PubMed 37976509 · DOI

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