Version May 2024
INTRODUCTION — The long-term outcome of acute low back pain is generally favorable. Rapid improvement in pain and disability and return to work are the norm in the first month [1]. Further improvement generally occurs over three months. However, given how common low back pain is, persistent symptoms affect millions of individuals. Subacute low back pain is commonly defined as back pain lasting between 4 and 12 weeks, and chronic low back pain is defined as pain that persists for 12 or more weeks. For those with chronic symptoms, few achieve the complete resolution they seek, but, rather, treatment focuses on controlling pain and improving activity.
This topic will address indications and outcomes of surgery for patients with subacute and chronic back pain who do not respond to more conservative treatment. Nonpharmacologic and pharmacologic treatment, as well as nonsurgical interventional therapies for patients with subacute and chronic low back pain, are discussed separately. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment" and "Subacute and chronic low back pain: Nonsurgical interventional treatment".)
Two related issues, surgical treatment for patients with lumbar stenosis and the initial management of patients with acute low back pain, are also discussed separately. (See "Lumbar spinal stenosis: Treatment and prognosis" and "Treatment of acute low back pain".)
INDICATIONS FOR SPINAL SURGERY — Only a small minority of patients suffering from low back pain ever require surgery. However, rates of surgical procedures are rising in the United States, particularly for spinal fusion in patients with nonspecific back pain [2].
For the small minority of low back pain patients with severe or progressive motor weakness, or signs and symptoms of cauda equina syndrome, urgent evaluation by a neurosurgeon or orthopedic surgeon with experience in back surgery is indicated (see "Lumbar spinal stenosis: Treatment and prognosis", section on 'Surgical treatment'). There is no evidence that early referral for surgery, in the absence of severe or progressive neurologic deficits, improves outcomes for lumbar disc prolapse with radiculopathy or symptomatic spinal stenosis [3,4].
The presence of mild foot drop or other minor motor deficits due to lumbar disc prolapse with radiculopathy is not an absolute indication for surgery, because many such patients will recover with nonsurgical treatment [3,4]. (See "Acute lumbosacral radiculopathy: Treatment and prognosis", section on 'Patients with disc herniation or spinal stenosis'.)
In the absence of severe or progressive weakness, or signs of cauda equina syndrome, surgery may be an elective option for patients with persistent disabling symptoms of low back pain and significantly impaired quality of life who have not responded to adequate trials of nonsurgical approaches. For lumbar disc prolapse with radiculopathy or symptomatic spinal stenosis, no randomized trial showing benefits of surgery has enrolled patients with less than four to six weeks of nonsurgical therapy. For nonspecific low back pain, trials of fusion surgery have only enrolled patients who have not responded to one year of nonsurgical therapies. Data are lacking on how to identify patients who are most likely to benefit from spinal fusion surgery. A systematic review of diagnostic tests found that immobilization, provocative discography, and temporary external fixation were not useful for identifying patients more likely to benefit from fusion surgery [5]. No studies of facet joint blocks or magnetic resonance imaging (MRI) met inclusion criteria. Evidence from observational studies and randomized trials suggest that psychologic factors may be the strongest predictors of low back pain outcomes, including outcomes following surgery [6,7]. Before referring to surgery, patients should be assessed for the presence of psychologic factors (depression, anxiety, or other mood disorders) that may decrease response to any treatment for subacute or chronic low back pain. (See "Unipolar depression in adults: Assessment and diagnosis" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)
Surgical interventions fall into two broad treatment categories: radicular pain conditions, most commonly due to disc herniation or spinal stenosis with or without degenerative spondylolisthesis; and nonspecific low back pain (often presumed to be related to degenerative changes in the intervertebral discs or facet joints).
NONSPECIFIC LOW BACK PAIN WITH DEGENERATIVE DISC CHANGES — Most patients with subacute and chronic low back pain and degenerative lumbar disc disease do not have radicular symptoms or symptoms attributable to a specific condition, and they are categorized as having nonspecific low back pain [8]. There is ongoing debate about the role for surgery in the treatment of chronic nonspecific low back pain. Surgery is not recommended for patients with nonspecific subacute low back pain. Regardless of treatment (disc replacement, fusion, or nonsurgical), few patients report complete symptom resolution.
Spinal fusion — The most common surgery for chronic nonspecific low back pain with lumbar disc degenerative changes is vertebral fusion, a procedure that unites (fuses) two or more vertebral bodies together. The goal is to restrict spinal motion and remove the degenerated disc (the presumed pain generator) in order to relieve symptoms. A variety of fusion techniques are practiced. All involve the placement of a bone graft between the vertebrae. Fusion can be performed with or without supplemental hardware (instrumentation), such as plates, screws, or cages, that serve as an internal splint while the bone graft heals. Fusion alters the normal mechanics of the spine and is associated with an increase in long-term degenerative changes in adjacent spine segments.
A systematic review of four randomized trials found that disability outcomes between lumbar vertebral fusion and nonsurgical treatment did not meet US Food and Drug Administration (FDA) criteria for clinically meaningful differences [9]. Enrolled patients had at least one year of low back pain that did not respond to standard nonsurgical therapy. Patients with significant psychiatric or somatic illness, ongoing compensation issues, or other chronic pain conditions were generally excluded. One randomized trial of 289 patients found fusion superior to unstructured nonsurgical therapy at two-year follow-up for decrease in pain (33 versus 7 percent), reduction in disability (25 versus 6 percent), return to work (36 versus 13 percent) and self-perception of improvement (63 versus 29 percent) [10]. Three trials found no clear or clinically relevant difference between surgery and nonsurgical treatment, but two trials were underpowered and a third trial had a high crossover rate between groups [11-13]. Four-year follow-up of two of these randomized trials again failed to demonstrate any benefit of spinal fusion surgery compared with cognitive intervention and exercises [14].
One factor for the inconsistent results between trials may be the nonsurgical treatment chosen as the comparator. In trials that showed no, or only modest, differences, the nonsurgical treatment was an intensive rehabilitation program incorporating a cognitive behavioral component [11-13]. In the trial that reported better results with surgery, the nonsurgical treatment intervention was less intensive and more heterogeneous [10]. The systematic review concluded that although methodologic flaws limit firm conclusions, surgery may be more effective than unstructured nonsurgical care but may not be more effective than intense rehabilitation with cognitive behavioral therapy [9]. A subsequent systematic review came to a similar conclusion [15].
Practice guidelines from the American Pain Society, based on this subsequent review, recommend that surgery be presented as an option to patients with persistent (>1 year) disabling nonradicular low back pain with discussion of its risks and benefits and with interdisciplinary rehabilitation discussed as similarly effective [16]. Shared decision-making with regard to surgery should take into account that most patients who undergo surgery will have some residual symptoms.
A Medicare advisory committee reviewed lumbar fusion surgery in older patients with low back pain related to degenerative disc disease. The report noted flaws in existing studies (poorly defined clinical conditions and outcomes, lack of standardization for control populations, few older adult patients, few randomized studies) and concluded that there was uncertainty regarding the effectiveness of lumbar fusion for older patients with chronic back pain [17].
A small (n = 41) trial published subsequent to the above reviews differed from previous studies in that it only enrolled patients with chronic low back pain who had single-level degenerative disc disease at L4/L5 or L5/S1, positive provocative discography, and positive response to a local anesthetic disc block. It allocated patients based on a minimization technique to surgery (anterior interbody fusion or posterolateral fusion with screws) versus a minimal exercise intervention (walking and stretching). Like the earlier trial that compared fusion with standard rehabilitation, this trial found that both surgical procedures were associated with lower pain scores and improved function compared with minimal exercise [18].
Randomized trials that directly compare different fusion techniques are inconsistent and do not permit reliable judgment about comparative benefits. The use of instrumentation is popular with some surgeons. A systematic review found that instrumentation was associated with improved fusion rates without a clear difference in clinical outcome [19]. The use of bone morphogenetic proteins (BMP) to speed bone fusion significantly increased between 2002 and 2006 in the United States [20]. In a large database sampling 20 percent of community hospitals in the United States, use of bone morphogenetic proteins for spinal fusion was associated with greater hospital costs and a longer hospital stay (3.2 percent increase after multivariable adjustment) but no difference in complication rates for lumbar procedures [20]. Two systematic reviews based on individual patient data each found no clear advantages of lumbar fusion with BMP over iliac crest bone graft (ICBG) in rates of overall success, fusion, or other measures of effectiveness [21,22]. The systematic reviews also found an association between use of BMP and risk of cancer (risk ratio [RR] 3.45, 95% CI 1.98-6.00) [21], although rates of cancer were low and the cancers were heterogeneous. Although the reviews found no clear differences in risk of other harms between BMP and ICBG, the rate of harms was high overall and substantially underreported in journal publications [21,23].
No operative deaths were reported in any of the trials comparing fusion with nonsurgical therapy. A systematic review that included observational data estimated the following complication rates for spinal fusion: in-hospital mortality, 0.2 percent; deep wound infection, 1.5 percent; deep vein thrombosis, 1.6 percent; pulmonary embolus, 2.2 percent; and nerve injury, 2.8 percent [24]. One trial found that more technically difficult procedures were associated with higher rates of complications but did not result in better overall outcome at two years [25].
Lumbar disc replacement — Artificial disc replacement is a newer alternative to fusion. A theoretic advantage of lumbar disc replacement compared with fusion is that a prosthetic disc could help preserve normal range of motion and spine mechanics. This could reduce the long-term degenerative changes in adjacent vertebral segments that have been observed following spinal fusion. However, the evidence suggests that the efficacy of this approach is similar to that of spinal fusion.
A 2012 systematic review of seven randomized trials evaluated the use of disc replacement for chronic low back pain [26]. Five trials (n = 1301) specifically compared disc replacement versus fusion for improvement of pain (visual analog score) and function (Oswestry Disability Index) outcomes at two years [27-31]. All studies had risk of bias due to lack of blinding and industry sponsorship; in addition, two of the trials evaluated an artificial disc that has not been approved by the FDA. Pooled results demonstrated no significant difference in pain scores between the two groups. There was a statistically, but not clinically, significant difference in improvement in function in the disc replacement group compared with the fusion group (4.3 points, 95% CI 1.9-6.7).
Only one trial has compared lumbar disc replacement versus a multidisciplinary rehabilitation program [32]. This study included 173 patients with chronic pain, disability, and L4-5 and/or L5-S1 degenerative disc disease. Those randomly assigned to disc replacement had a statistically, but not clinically, significant improvement in disability score (difference of 8 points on a 100 point scale) at two-year follow-up and lower pain scores (difference 12 points on a 100 point scale) compared with the rehabilitation arm. Six patients in the surgery group had complications resulting in physical impairment, with one patient requiring a lower leg amputation following revision surgery. No major complications were reported for the rehabilitation arm.
Two randomized trials found no clear differences between different artificial discs [33,34].
Our approach is consistent with guidelines from the American Pain Society, which found insufficient supporting evidence regarding long-term benefits and harms of disc replacement to recommend the procedure [16]. A key limitation of existing evidence for the role of lumbar disc replacement is the lack of longer-term follow-up to assess efficacy and failure rates necessitating device removal and potential conversion to a fusion procedure. Regardless of treatment (disc replacement, fusion, or nonsurgical), few patients report complete symptom resolution.
Disc replacement is approved by the FDA for patients who are in good health and ≤60 years old, with disease limited to one disc between L3 and S1 and no associated deformity, spondylolisthesis, or neurologic deficit. If undertaken, patients should be treated by surgeons experienced in performing disc replacement to minimize complications and length of hospitalization [35].
Nucleus pulposus prostheses have been evaluated in randomized trials or are under development but have not yet been approved by the FDA.
LUMBAR DISC PROLAPSE — The purpose of surgery for symptomatic lumbar disc prolapse is to relieve symptoms due to inflammation of, or pressure on, affected nerve roots by removing part of, or the entire, disc.
A variety of discectomy techniques are available:
●The traditional open discectomy is performed with a standard surgical incision, often with the aid of eyepiece (loupe) magnification. It frequently involves a laminectomy (removal of the vertebral lamina to relieve pressure on nerve roots).
●Microdiscectomy, a refinement of open discectomy, has become the most common procedure and can be performed on an outpatient basis. It involves a smaller incision in the back, with visualization through an operating microscope, followed by a hemilaminectomy (removal of part of the lamina in order to adequately visualize the disc) and removal of the disc fragment compressing the affected nerve or nerves.
●Minimally invasive techniques include percutaneous manual nucleotomy, percutaneous discectomy, laser discectomy, endoscopic discectomy, microendoscopic discectomy, and radiofrequency nucleoplasty [36]. Tubular or trochar discectomy is a less invasive technique in which a tubular retractor is inserted over a guidewire, gaining access to the disc by muscle splitting rather than muscle incision and detachment [37].
Minimally invasive techniques involve smaller incisions and surgery with the aid of indirect visualization; some techniques employ lasers to vaporize parts of the disc or automated techniques for removing portions of the disc. They have the potential advantage of quicker recovery from surgery compared with standard open discectomy or microdiscectomy.
Major postoperative complications are rare for any of the discectomy procedures [38-40].
Standard open discectomy or microdiscectomy
Compared with no surgery — Randomized trials comparing surgery with nonsurgical management for lumbar disc prolapse with persistent radiculopathy indicate that patients who undergo surgery experience faster and larger improvements, though substantial improvements are observed regardless of whether patients undergo surgery or not, and in some studies, outcomes appear similar within two years [4,38,39,41,42]. The available randomized trials have not been blinded and, thus, are likely to be influenced by a patient's expectations of treatment results. In addition, the no-surgery comparators vary across trials, complicating interpretation.
An early trial comparing surgery with nonsurgical therapy (inpatient rehabilitation) for lumbar disc prolapse with nerve root compression (duration of symptoms not reported) found one-year outcomes for standard open discectomy superior, with a lower likelihood of poor results (odds ratio [OR] 0.37, 95% CI 0.14-0.99), although differences were no longer present after 4 to 10 years [4]. In addition, one-quarter of patients initially assigned to nonsurgical therapy eventually underwent surgery, making longer-term results difficult to interpret.
The Spine Patient Outcomes Research Trials (SPORT) are multicenter, randomized trials, with associated prospective cohort studies, evaluating surgery versus nonsurgical therapy for three spinal conditions: lumbar disc herniation, spinal stenosis without degenerative spondylolisthesis, and spinal stenosis with degenerative spondylolisthesis [43]. The SPORT trial of surgery for prolapsed lumbar disc (symptoms present at least six weeks) found standard open discectomy or microdiscectomy (technique left to discretion of the surgeon) no better than nonoperative treatment (including physical therapy, education/counseling, and nonsteroidal anti-inflammatory drugs [if tolerated]) for pain relief and improvement in function after three months [39]. Patients in both groups improved an average of 20 to 30 points (on a 100-point scale) on pain and functional status scores. Results up to four [44] and eight [45] years showed persistent, comparable benefits for surgical and nonoperative treatment in an intention-to-treat analysis for the primary outcomes of pain, physical function, and disability. Secondary outcomes (sciatica bothersomeness, self-rated improvement, and patient satisfaction with symptoms) were better for the group assigned to surgery [45]. These results likely underestimate the relative benefit of surgical treatment, since approximately half of the patients assigned to either arm crossed over to the other intervention. Additional analysis found no difference on the duration of symptoms [46].
A concurrent prospective cohort study of SPORT patients who met eligibility criteria but declined randomization reported moderate benefits of surgery compared with nonoperative treatment at three months through two years (10 to 15 points on the 0 to 100 SF-36 bodily pain scale; 12 to 15 points on the 0 to 100 SF-36 physical function scale; 2 to 4 points on the 0 to 24 Sciatica Bothersomeness Index) after adjusting for potential confounders [47]. These results were similar to those of an on-treatment analysis of the randomized trial [39]. A combined analysis at four and eight years included all patients from the randomized trial and observation cohort who underwent surgery and compared them with patients who had nonsurgical treatment [44,45]. Patients who had surgery for lumbar disc herniation, compared with those who did not undergo surgery, had greater improvement for all outcomes evaluated (pain, functional status, and disability indices) other than work status.
A cost-effectiveness analysis using SPORT data from 775 surgical patients and 416 nonoperative patients (including randomized trial and observational cohorts) found that surgery, compared with nonoperative care, resulted in higher costs but better health outcomes at two years [48]. The cost per quality-adjusted life year (QALY) gained with surgery ranged from USD $34,000 to $69,000, depending upon imputed surgical costs, and was comparable with other commonly accepted health care interventions. The cost per QALY gained with surgery decreased when re-evaluated at four years, indicating increasing value for surgery, compared with nonoperative management with longer follow-up [49].
Three additional randomized trials compared outcomes for early microdiscectomy or initial nonsurgical treatment in patients with lumbar disc herniation and radicular pain [38,42,50]. Two trials evaluated patients with subacute symptoms [38,42] and one trial [50] enrolled patients with chronic (4 to 12 months) symptoms. Across the trials, approximately 34 to 40 percent of patients assigned to initial nonsurgical treatment underwent surgery.
●In a trial including 283 patients with sciatica symptoms for 6 to 12 weeks, 125 underwent microdiscectomy at a mean of 2.2 weeks after enrollment; 55 of the 142 patients assigned to conservative therapy (education, analgesics, and physiotherapy) had surgery at a mean of 19 weeks [38]. There was no difference in disability scores after one year between the group assigned to early surgery or conservative treatment. Patients assigned to surgery reported a faster rate of perceived recovery (hazard ratio [HR] 1.97, 95% CI 1.72-2.22). A concurrent cost utility analysis found surgery likely to be cost-effective from a societal perspective [51].
Perceived recovery at one year for both groups was 95 percent, although patient satisfaction decreased for both groups with longer term follow-up. At two years, there was no difference in patient reports of unsatisfactory outcomes (20 percent) or disability scores between the two groups [52].
●A randomized trial including 58 patients with symptoms for 6 to 12 weeks found no difference between microdiscectomy and nonsurgical therapy (isometric exercises) on any outcome after two years [42].
●A randomized trial including 790 patients with sciatica for 4 to 12 months found microdiscectomy decreased leg pain intensity at six months (mean difference 2.4 points on a 0 to 10 scale) compared with nonsurgical treatment (education, activity, exercise, oral analgesics, and physiotherapy; epidural glucocorticoid injections were permitted); results were similar at 12 months (mean difference 2.1 points) [50]. Surgery was also associated with better function (mean difference 11.8 points on the Oswestry Disability Index) and SF-36 Physical and Mental Component Summary scores at 12 months (difference -8.7 and -5.7 points on a 0 to 100 scale, respectively).
In a 2023 meta-analysis of 12 trials (including the five trials described above) comparing any surgical treatment with any nonsurgical treatment among patients with sciatica due to lumbar disc herniation, discectomy reduced leg pain at immediate- and short-term follow-up, but no greater benefits on pain or disability were noted at one-year compared with nonsurgical treatment [53].
Guidelines from the American Pain Society recommend that clinicians discuss risks and benefits of surgery with patients who have persistent, disabling radiculopathy due to a herniated lumbar disc [16]. Shared decision-making regarding surgery should be based on understanding that benefits are moderate on average and decrease over time compared with patients who do not choose to have surgery.
Comparing open discectomy with microdiscectomy — Microdiscectomy is performed with an operating microscope through a smaller incision than open discectomy and has become the standard surgical procedure for lumbar disc herniation. Four trials found no clear differences between standard open discectomy and microdiscectomy in patients with lumbar disc herniation and radiculopathy [54-57].
Minimally invasive procedures — Minimally invasive surgical approaches that utilize techniques to further reduce incision size and the area of dissection have been introduced as potential alternatives to standard open discectomy and microdiscectomy. Until more definitive evidence is available showing clear advantages for alternative surgical techniques, our preference is for standard microdiscectomy or open discectomy for patients with lumbar disc herniation and radiculopathy who are appropriate surgical candidates [58,59].
A 2014 review of 11 randomized or quasi-randomized trials suggested that, compared with open discectomy or microdiscectomy, minimally invasive procedures are associated with less surgical site infections, but they may be inferior for relief of leg and back pain and rehospitalization due to recurrent disc herniation [58]. The minimally invasive procedures evaluated in the review were percutaneous endoscopic lumbar discectomy (eight trials), transmuscular tubular microdiscectomy (two trials), and automated percutaneous discectomy (one trial).
Other trials have evaluated other minimally invasive procedures:
●One small (n = 62) trial compared percutaneous disc decompression with conservative therapy (medications, physical therapy, education, counseling) [60]. Percutaneous disc decompression was associated with higher pain scores at three months (3.0 versus 0.9 on a 0 to 10 scale), but lower pain scores at one year (1.6 versus 4.0) and at two years (1.7 versus 4.0). Challenges in interpreting this trial are that it used an inadequate randomization method (alternate allocation), and it is unclear why decompression would have a delayed effect, as most trials have shown that benefits of discectomy are most pronounced at short-term follow-up.
●A randomized but unblinded trial in one center compared standard microdiscectomy and simple fragment excision (microscopic sequestrectomy, a procedure in which disc fragments are removed without entering the disc space itself) in 84 patients with single-level disc herniation and no prior surgery [61]. Both groups improved substantially immediately following surgery. At two-year follow-up, rates of reherniation between the groups did not differ, while self-reported motor function improved over time for the sequestrectomy group, and worsened for the microdiscectomy group. Longer-term outcomes and confirmation of these findings by additional studies are needed before the limited procedure can be routinely recommended.
There are no published trials comparing other minimally invasive techniques (eg, laser-assisted discectomy) versus open discectomy, microdiscectomy, or nonsurgical therapy.
Postoperative physiotherapy — There is no evidence that patients need to have activity restricted following first-time lumbar surgery. Although commonly prescribed following surgery, the effectiveness of formal postoperative physiotherapy is uncertain.
A systematic review, including literature published through 2001, found a lack of high-quality studies and insufficient evidence that physiotherapy immediately following lumbar disc surgery is effective, although it did not cause harm [62]. On the other hand, intensive exercise programs started four to six weeks after surgery were more effective than mild exercise programs for short-term improvement in function and return to work, with no difference in long-term outcomes. The components and intensity of physiotherapy ranged widely in the included trials, and an optimal postoperative rehabilitation regimen could not be identified.
A single-blind randomized study of 120 patients with uncomplicated lumbar disc surgery evaluated a 12-week course of immediate physiotherapy compared with sham therapy (neck massage) or no therapy; all patients received education on ergonomics, lifestyle changes, and back exercises [63]. Scores for low back pain at 12 weeks were better for physiotherapy than no treatment but were not significantly different for physiotherapy or sham therapy, suggesting that psychological factors and patient expectations may have influenced outcome. There were no differences between outcomes for any group at long-term (1.5 years) follow-up.
SPINAL STENOSIS OR DEGENERATIVE SPONDYLOLISTHESIS — Spondylolisthesis refers to slippage of a vertebral body over another, usually with the superior vertebral body slipping anteriorly relative to an adjacent inferior vertebral body (anterolisthesis). Retrolisthesis refers to posterior slippage. Degenerative spondylolisthesis, usually caused by degenerative changes at the facet joints and intervertebral discs, is a common cause of spinal stenosis. Degenerative spondylolisthesis leads to a loss of normal structural supports and subluxation of the affected vertebral body and can cause pain and neurologic deficits due to spinal stenosis or tension on nerve roots. The most common site for degenerative spondylolisthesis is L4.
Surgery may be beneficial in patients with persistent symptoms related to spinal stenosis (narrowing of the spinal canal), although the benefit of surgery, compared with nonsurgical therapy, declines over time. Decompressive laminectomy, with or without fusion, is the most common surgery for spinal stenosis and symptomatic degenerative spondylolisthesis. Surgical options and outcomes for spinal stenosis and degenerative lumbar spondylolisthesis are discussed in detail separately. (See "Lumbar spinal stenosis: Treatment and prognosis", section on 'Surgical treatment'.)
SPONDYLOLYSIS AND ISTHMIC SPONDYLOLISTHESIS — Spondylolysis refers to a defect in the pars interarticularis (a bone connecting one facet joint to another) (figure 1). Spondylolysis is often asymptomatic and detected incidentally as a radiologic finding, although it may also be associated with low back pain. Approximately 90 percent of spondylolysis occurs at L5 [64]. It is seen in approximately 6 percent of the adult population [64] but may be more frequent among adolescent athletes. Symptoms resolve spontaneously in many persons with symptomatic spondylolysis. Treatment is controversial as there are no randomized trials to guide treatment options. Treatment options for symptomatic spondylolysis include bracing, activity restriction, and physical therapy. (See "Back pain in children and adolescents: Causes", section on 'Spondylolysis and spondylolisthesis' and "Spondylolysis and spondylolisthesis in child and adolescent athletes: Management" and "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis".)
Isthmic spondylolisthesis differs from degenerative spondylolisthesis in that a lytic defect in the pars interarticularis (lytic spondylolysis) results in anterior subluxation (slippage) of the affected vertebral body (figure 2). The subluxation may also place stress on the adjacent intervertebral disc, resulting in degenerative disc disease. The most common site of isthmic spondylolisthesis, L5, can cause back pain or radicular symptoms due to tension or compression on the L5 nerve root. Initial treatment for symptomatic isthmic spondylolisthesis is similar to treatment for spondylolysis. Surgical treatment is reserved for patients who do not respond to nonsurgical therapies. Potential indications for surgery include progressive slip, development of neurologic deficits, and segmental instability associated with pain. Segmental instability is typically diagnosed using a combination of imaging (dynamic slippage with extension or flexion) and clinical findings (frequent exacerbations of back symptoms with minimal provocation). The most common surgical procedure for isthmic spondylolisthesis is posterolateral (transpedicular) fusion, with or without decompressive laminectomy.
Evidence on efficacy of surgery versus nonsurgical therapy for isthmic spondylolisthesis is limited to one randomized trial (n = 114). In patients with low back pain and sciatica for at least one year, posterolateral fusion was associated with moderately decreased pain (mean score 37 versus 56 on a 0 to 100 scale) and disability (mean Disability Rating Index 29 versus 44 on a 0 to 100 scale) and superior patient-reported overall outcomes (74 versus 43 percent better or much better) after two years compared with an exercise program [65]. After an average of nine years' follow-up, however, differences were small and no longer significant for pain or function [66].
Evidence on efficacy of different surgical techniques for isthmic spondylolisthesis is also limited. One trial (n = 42) found fusion plus decompressive laminectomy associated with worse outcomes compared with fusion alone [67], and another (n = 77) found no difference in clinical outcomes between instrumented and non-instrumented fusion [68].
INTRACTABLE LOW BACK PAIN — Patients may have persistent, disabling low back pain despite use of several standard therapies or following back surgery (ie, failed back surgery syndrome). Though there are no well-proven treatments available for these patients, referral to clinicians experienced in treating intractable back pain should be considered when standard interventions have failed. Evaluation in an interdisciplinary pain clinic may include treatments to control pain, improve function, and provide behavioral support that may not be available in the primary care setting.
Pharmacotherapy, including consideration of chronic opioid therapy, may be used in such patients to manage pain. However, for opioid therapy, responses are incomplete, long-term outcomes are unknown, and risks of harm are significant. Opioids should only be used after adequate risk assessment and with appropriate monitoring and supervision. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Opioids'.)
Spinal cord stimulation — For patients with persistent, disabling radicular pain after prior spine surgery, we offer spinal cord stimulation as a "last resort" option, as part of a shared decision-making process that highlights the lack of consistently demonstrated benefit in clinical trials and the relatively high rate of device-related complications. This approach is consistent with guidelines from the American Pain Society [16]; however, these guidelines were developed prior to the publication of the only placebo-controlled trial, which did not show benefit [69,70].
Spinal cord stimulation involves the placement of electrodes in the epidural space adjacent to the spinal area presumed to be the source of pain. An electric current is then applied to achieve sympatholytic and other neuromodulatory effects. The number and type of electrode leads and parameters of electrical stimulation can vary. Electrodes may be implanted percutaneously or by laminectomy, and power for the spinal cord stimulator is supplied by an implanted battery or transcutaneously through an external radiofrequency transmitter.
Complications are not rare. In the randomized trials, 18 to 32 percent of patients experienced a complication following spinal cord stimulator implantation, including electrode migration, infection or wound breakdown, generator pocket-related complications, and lead problems [69-72].
●Pain after spine surgery – Spinal cord stimulation has been evaluated for persistent radicular low back pain after spine surgery in randomized trials; each utilized a different comparator (surgery, medical management, or placebo):
•One randomized trial (n = 50) of patients with persistent radicular low back pain after surgery found spinal cord stimulation superior to reoperation for achieving >50 percent pain relief after a mean of 2.9 years (38 versus 12 percent) [71].
•A second randomized trial (n = 100) of patients with persistent radicular pain following surgery for herniated disc found spinal cord stimulation associated with greater likelihood of experiencing >50 percent pain relief at six months compared with conventional medical management (48 versus 9 percent) [72].
•In a crossover trial among 50 patients with chronic radiculopathy after lumbar spine surgery, spinal cord burst stimulation was not superior to placebo for improving pain-related disability [69]. In a post hoc follow-up study conducted six months after unblinding, pain-related disability scores were similar between the spinal cord burst stimulation and placebo groups [70].
Studies evaluating spinal cord stimulation for patients with primarily axial, rather than radicular, back pain are limited, and therefore, the role of spinal cord stimulation for patients with axial pain after prior spine surgery is unclear.
●Pain not associated with spine surgery – No randomized trials have evaluated the effectiveness of spinal cord stimulation for low back pain not associated with prior surgery. In a retrospective propensity-matched comparison of spinal cord stimulation to medical management among 7560 adults with chronic pain (71 percent failed back surgery, 10 percent complex regional pain, 26 percent chronic pain, and 0.8 percent other back/extremity pain), spinal cord stimulation was not associated with a reduction in use of opioids, pain injections, radiofrequency ablation, or spine surgery at two years [73]. Further, 17.9 percent of those treated with spinal cord stimulation experienced complications, and 22.1 percent had device revisions and/or removals.
Details of available spinal cord stimulators, indications for use, and techniques for placement are reviewed in detail elsewhere. (See "Spinal cord stimulation: Placement and management".)
Other therapies — Other therapies include intrathecal opioids or ziconotide [74] and adhesiolysis (injection of isotonic saline, hypertonic saline, or hyaluronidase into the epidural space in order to facilitate lysis of adhesions); randomized trials for these interventions are not available or inconclusive.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower spine disorders".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Low back pain in adults (The Basics)")
●Beyond the Basics topic (see "Patient education: Low back pain in adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Subacute low back pain is commonly defined as back pain lasting between 4 and 12 weeks, and chronic low back pain is defined as pain that persists for 12 or more weeks. For those with chronic symptoms, few achieve the complete resolution they seek, but rather treatment focuses on controlling pain and improving activity. (See 'Introduction' above.)
●Indications for spinal surgery – We suggest not performing surgery for most patients with chronic symptoms attributed to nonspecific low back pain (Grade 2B). Decisions regarding surgery should be based on shared decision-making. We suggest that surgery be limited to patients with nonspecific low back pain who meet the following criteria: persistent symptoms with associated disability last for at least one year despite nonsurgical interventions; the patient is an appropriate surgical candidate; and intensive rehabilitation with a cognitive behavioral therapy component is either not available or has not been effective (Grade 2B). (See 'Indications for spinal surgery' above and 'Nonspecific low back pain with degenerative disc changes' above.)
●Spinal fusion surgery for nonspecific low back pain with degenerative changes – Vertebral fusion is the most common surgery for chronic, nonspecific low back pain. Surgical instrumentation (use of pedicle screws or other hardware) increases fusion rates, but it is not known if instrumentation improves clinical outcomes. More research with longer follow-up is needed to determine the appropriate role of artificial disc replacement versus fusion. We suggest that vertebral fusion be performed for patients who undergo surgical intervention for chronic low back pain (Grade 2B). (See 'Spinal fusion' above.)
●Discectomy for lumbar disc prolapse – In patients with lumbar disc prolapse and radiculopathy who do not have severe or progressive neurologic deficits, there is no evidence that early referral for surgery improves outcomes. Outcomes for patients who undergo discectomy, compared with nonsurgical therapy, favor surgery at short-term follow-up; however, in some trials, results are equivalent after one to two years. The optimal timing of surgery is uncertain, although benefits have been observed in patients even with subacute or chronic symptoms. (See 'Lumbar disc prolapse' above.)
Minimally invasive discectomy techniques have not been demonstrated to be superior to traditional discectomy methods and may not be applicable for many patients. For patients with lumbar radicular symptoms of at least 6 to 12 weeks who are good surgical candidates and desire surgery based on shared decision-making, we suggest either open discectomy or microdiscectomy (Grade 2B). Earlier surgery may be indicated for patients with severe and disabling pain related to lumbar disc prolapse that is unresponsive to medical therapy. (See 'Lumbar disc prolapse' above.)
●Laminectomy for lumbar spinal stenosis – Surgery may be beneficial in patients with persistent symptoms related to spinal stenosis. For patients who undergo laminectomy compared with nonsurgical therapy, outcomes favor surgery at short-term follow-up but not at longer follow-up. (See "Lumbar spinal stenosis: Treatment and prognosis", section on 'Surgical treatment'.)
●Surgical fusion for spondylolysis and isthmic spondylolisthesis – In patients with persistent symptoms related to isthmic spondylolisthesis, surgical fusion may result in early benefits compared with nonsurgical treatment. However, benefits do not persist with longer follow-up. (See 'Spondylolysis and isthmic spondylolisthesis' above.)
●Intractable low back pain – Patients with intractable back pain, who are not surgical candidates or in whom surgery has not been successful, should be referred to chronic pain specialists, preferably in the setting of an interdisciplinary pain clinic.
●Spinal cord stimulation for intractable low back pain – For patients with persistent, disabling radicular pain after surgery, we offer spinal cord stimulation as a "last resort" option, as part of a shared decision-making process that highlights the lack of consistently demonstrated benefit in clinical trials and the relatively high rate of device-related complications. (See 'Intractable low back pain' above.)
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