BACK PAIN, LUMBAR FUSION, AND COGNITIVE BEHAVIORAL TREATMENT

A recent study in the Journal of Pain (122, 2006, pp 145-155) compared the effectiveness of lumbar fusion with a course of cognitive education and exercise in patients who had undergone previous, less invasive surgeries (failed back). This was a prospective study with sixty patients cleared for fusion surgery, randomized either to lumbar fusion or cognitive education and exercise. One year post treatment, there was no statistical difference between fusion and cognitive/exercise groups in the primary outcome of back specific pain and disability as measured by their score on the Oswestry Disability Index. The success rate was 50% in the fusion group and 48% in the cognitive/exercise group. Specific secondary measures at one year were also assessed including mean pain severity, general function, emotional distress, fear avoidance, work status, and fingertip to floor distance. There was no significant difference between groups except that the cognitive education and exercise group had less fear avoidance and greater fingertip to floor distance. The authors concluded there was no evidence of greater benefit from lumbar fusion following a failed back surgery over cognitive education and exercise. This is an extraordinary finding for those people with failed back surgery who are considering lumbar fusion, especially given the risks of fusion and the grueling post op period. There are situations where lumbar fusion after failed back surgery is medically necessary, but the authors express great concern about the high rate of unnecessary fusions after back surgery.