Disc Replacement Surgery for Low Back Pain Improves Long-Term Outcomes

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Spinal fusion, which restricts segmental motion, is the conventional surgical treatment for low back pain associated with degenerative disc disease.
Spinal fusion, which restricts segmental motion, is the conventional surgical treatment for low back pain associated with degenerative disc disease.

Long-term, clinically important improvement in chronic low back pain can be achieved with lumbar total disc replacement and multidisciplinary rehabilitation in patients whose low back pain does not respond to conservative therapy, according to a study  published in The Spine Journal.1

Multidisciplinary rehabilitation is an effective treatment for low back pain.2 Spinal fusion, which restricts segmental motion, is the conventional surgical treatment for low back pain associated with degenerative disc disease. Limited data suggest that lumbar total disc replacement, which aims to preserve segmental motion, may have greater efficacy than spinal fusion. However, the evidence is not conclusive, and as a result, US insurance carriers do not cover single level lumbar total disc replacement as treatment for chronic low back pain.1

Spinal fusion and multidisciplinary rehabilitation have shown similar effectiveness as short- and long-term treatments in patients with low back pain and degenerative disc disease.1 Only one randomized trial has compared lumbar total disc replacement with multidisciplinary rehabilitation, and the results favored disc replacement in the short term (2 years).3

In the present study, Håvard Furunes, MD, from the Innlandet Hospital Gjøvik in Norway, and colleagues compared the long-term efficacy of lumbar total disc replacement vs multidisciplinary rehabilitation in patients with chronic low back pain associated with degenerative disc disease.1


A total of 173 patients were randomly assigned to lumbar total disc replacement surgery or multidisciplinary rehabilitation. Of these, 151 were available for follow-up at 8 years. The primary end point was disability and pain as measured by the Oswetry Disability Index (ODI) score (range 0 to 100; higher scores correspond to greater pain and disability).

At 8 years, surgery and rehabilitation improved ODI scores by 20.0 points (P ≤.0001) and 14.4 points (P ≤.0001), respectively. On average, the surgery group had ODI scores that were 8.1 points higher than the ODI scores in the rehabilitation group (P =.01).

Clinically important improvement, defined as an ODI score improvement of ≥15 points, was reported by 70% of the surgery group and 50% of the rehabilitation group (P =.03).

Nearly one-quarter of patients in the surgery group reported full recovery, compared with 6% of patients in the rehabilitation group (P =.002).

Summary and Clinical Applicability

Lumbar total disc replacement is a surgical treatment for low back pain that preserves segmental motion, and may be more effective than spinal fusion for treating chronic low back pain with degenerative disc disease. Spinal fusion has efficacy similar to multidisciplinary rehabilitation in the treatment of chronic low back pain in this population. Researchers found that both lumbar total disc replacement and multidisciplinary rehabilitation produced clinically important improvement in low back pain, with results favoring surgery.

“The long-term results of lumbar total disc replacement in patients with chronic low back pain and degenerative intervertebral disc changes are acceptable and in line with the short-term results. On the other hand, the long-term results of multidisciplinary rehabilitation in this population are also acceptable,” Dr Furunes told Clinical Pain Advisor. He recommends rehabilitation as first-line treatment in patients with chronic low back pain and degenerative disc disease because a significant percentage of patients achieved clinical improvement with rehabilitation, and because surgery may be associated with complications.

Dr Furunes also noted that while one-quarter of patients experienced complete resolution of back pain at 8 years, 8% reported that they were “worse than ever.” “This illustrates the obvious need for further research on predictors for good and bad outcome following disc replacement,” he said.

Limitations

Patients were excluded if they had nerve root involvement or generalized disc degeneration, which may limit the generalizability of the study results.

The crossover rate from rehabilitation to surgery (24%) and the reoperation rate (14%) in the surgery group were high. 

 

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References

  1. Furunes H, Storheim K, Brox JI, et al. Total disc replacement versus multidisciplinary rehabilitation in patients with chronic low back pain and degenerative discs: Eight-year follow-up of a randomized controlled multicenter trial. [published online June 2, 2017] Spine J. doi:10.1016/j.spinee.2017.05.011.
  2. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev. 2014;(9):CD000963. doi:10.1002/14651858.CD000963.pub3.
  3. Hellum C, Johnsen LG, Storheim K, et al; Norwegian Spine Study Group. Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: two year follow-up of randomised study. BMJ. 2011;342:d2786. doi:10.1136/bmj.d2786.
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