8th November 2005: MRC Spine Stabilisation Trial. A trial comparing operative and non-operative treatments for chronic back pain.

Patients suffering from chronic low back pain may obtain nearly as much benefit from a programme of intensive physical exercise as they would from spinal surgery. These results from the MRC spine stabilisation trial should help doctors and service providers make decisions about the best management for this population. Mr Jeremy Fairbank of the Nuffield Orthopaedic Centre in Oxford led the clinical trial that involved 15 hospitals in England and Scotland. A total of 349 patients aged 18-55, who had suffered chronic low back pain for at least a year, were randomly assigned either to undergo spinal fusion surgery or to partake in a three-week intensive programme of rehabilitation, involving daily exercises and cognitive behavioural therapy.

After two years, patients in both groups had improved, experiencing less pain and disability and more mobility. 29% of the rehabilitation patients subsequently received a spinal fusion. The fusion group improvement had a small statistical advantage in Oswestry Disability index (4.5 oswestry points), which is of arguable clinical significance. When health costs over 2 years are taken into account, the "surgery first" strategy is twice as expensive as the "intensive rehabilitation first". Surgery has been shown to be at an advantage over "usual medical care" in another trial report from Sweden.

Spinal fusion surgery has been used to treat low back pain for 90 years, with little evidence that it is more effective than intensive exercise treatments. Mr Fairbank said: "Our results suggest that patients eligible for surgery should be offered this type of rehabilitation programme first. We believe it is safer and cheaper than using surgery as the first line of treatment, when conventional physiotherapy and alternative therapy have failed."

BMJ 330: 1233-1239,1239-1243

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