• Mohamad Bydon, Rafael De la Garza-Ramos, Mohamed Macki, Abdul Baker, Aaron K Gokaslan, and Ali Bydon.
• *Department of Neurosurgery, Johns Hopkins University School of Medicine †Johns Hopkins Spinal Column Biomechanics and Surgical Outcomes Laboratory, Baltimore, MD.
• J Spinal Disord Tech. 2014 Jul 1;27(5):297-304.

Study DesignSystematic review and meta-analysis of randomized controlled trials (RCTs).ObjectiveTo evaluate the current evidence comparing lumbar fusion to nonoperative management for the treatment of chronic discogenic low back pain.Background And ContextDiscogenic low back pain is a common and sometimes disabling condition. When the condition becomes chronic and intractable, spinal fusion may play a role.MethodsA systematic review of the literature was conducted using the PubMed and CENTRAL databases. We included RCTs that compared lumbar fusion to nonoperative management for the treatment of adult patients with chronic discogenic low back pain. A meta-analysis was conducted to assess the improvement in back pain based on the Oswestry Disability Index (ODI).ResultsFive RCTs met our inclusion criteria. A total of 707 patients were divided into lumbar fusion (n=523) and conservative management (n=134). Although inclusion/exclusion criteria were relatively similar across studies, surgical techniques and conservative management protocols varied. The pooled mean difference in ODI (final ODI-initial ODI) between the nonoperative and lumbar fusion groups across all studies was -7.39 points (95% confidence interval: -20.26, 5.47) in favor of lumbar fusion, but this difference was not statistically significant (P=0.26).ConclusionsDespite the significant improvement in ODI in the lumbar fusion groups in 3 studies, pooled data revealed no significant difference when compared with the nonoperative group. Although there was an overall improvement of 7.39 points in the ODI in favor of lumbar fusion, it is unclear that this change in ODI would lead to a clinically significant difference. Prospective randomized trials comparing a specific surgical technique versus a structured physical therapy program may improve evidence quality. Until then, either operative intervention by lumbar fusion or nonoperative management and physical therapy remain 2 acceptable treatment methods for intractable low back pain.

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