Advertisement

Conservative Care in Lumbar Spine Surgery Trials: A Descriptive Literature Review

Published:August 27, 2016DOI:https://doi.org/10.1016/j.apmr.2016.07.025

      Abstract

      Objective

      To evaluate the degree to which conservative care and failure were specifically defined in studies comparing nonoperative treatment versus surgery for low back pain (LBP) conditions in adults.

      Data Sources

      A comprehensive literature search was conducted by an experienced librarian using MEDLINE (PubMed), Embase, Google Scholar, and CENTRAL from January 2003 to June 2014. Endnote bibliographic management application was used to remove duplicates and organize the citations.

      Study Selection

      Prospective, randomized, or cohort trials comparing surgery versus conservative intervention for patients with LBP conditions. Study selection was conducted by 2 independent reviewers.

      Data Extraction

      Three independent reviewers extracted data from each article using a structured data extraction form. Data extracted included type of study, participant characteristics, sample size, description, and duration of conservative care and whether failed conservative care criterion was defined.

      Data Synthesis

      A total of 852 unique records were screened for eligibility; of those, 72 articles were identified for further full-text review. Thirty-four full texts were excluded based on the exclusion criteria, and 38 articles, representing 20 unique studies, were included for qualitative synthesis. Fifteen of the 20 studies defined the duration of conservative care. Only 3 studies defined the dosage of physical therapy sessions, including total number of visits and visit duration. Two studies described medication usage, including the duration and type. No studies specifically defined what constituted failed conservative therapy.

      Conclusions

      This literature review suggests conservative care is poorly defined in randomized trials, which can lead to ambiguity of research procedures and unclear guidelines for clinicians. Future studies should increase transparency and explicitly define conservative care.

      Keywords

      List of abbreviations:

      LBP (low back pain)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Krismer M.
        • van Tulder M.
        Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific).
        Best Pract Res Clin Rheumatol. 2007; 21: 77-91
        • Hooten W.M.
        • Cohen S.P.
        Evaluation and treatment of low back pain: a clinically focused review for primary care specialists.
        Mayo Clin Proc. 2015; 90: 1699-1718
        • Walker B.F.
        The prevalence of low back pain: a systematic review of the literature from 1966 to 1998.
        J Spinal Disord. 2000; 13: 205-217
        • Crow W.T.
        • Willis D.R.
        Estimating cost of care for patients with acute low back pain: a retrospective review of patient records.
        J Am Osteopath Assoc. 2009; 109: 229-233
        • Deyo R.A.
        • Mirza S.K.
        • Martin B.I.
        Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002.
        Spine (Phila Pa 1976). 2006; 31: 2724-2727
        • Hart L.G.
        • Deyo R.A.
        • Cherkin D.C.
        Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey.
        Spine (Phila Pa 1976). 1995; 20: 11-19
        • Chou R.
        • Qaseem A.
        • Snow V.
        • et al.
        Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
        Ann Intern Med. 2007; 147: 478-491
        • Dagenais S.
        • Tricco A.C.
        • Haldeman S.
        Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines.
        Spine J. 2010; 10: 514-529
        • Manusov E.G.
        Surgical treatment of low back pain.
        Prim Care. 2012; 39: 525-531
        • Jacobs W.C.
        • Rubinstein S.M.
        • Koes B.
        • van Tulder M.W.
        • Peul W.C.
        Evidence for surgery in degenerative lumbar spine disorders.
        Best Pract Res Clin Rheumatol. 2013; 27: 673-684
        • Chou R.
        • Baisden J.
        • Carragee E.J.
        • Resnick D.K.
        • Shaffer W.O.
        • Loeser J.D.
        Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline.
        Spine (Phila Pa 1976). 2009; 34: 1094-1109
        • Airaksinen O.
        • Brox J.I.
        • Cedraschi C.
        • et al.
        Chapter 4. European guidelines for the management of chronic nonspecific low back pain.
        Eur Spine J. 2006; 15 Suppl 2: S192-S300
        • Haldeman S.
        • Dagenais S.
        A supermarket approach to the evidence-informed management of chronic low back pain.
        Spine J. 2008; 8: 1-7
        • Delitto A.
        • Piva S.R.
        • Moore C.G.
        • et al.
        Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial.
        Ann Intern Med. 2015; 162: 465-473
        • Zaina F.
        • Tomkins-Lane C.
        • Carragee E.
        • Negrini S.
        Surgical versus non-surgical treatment for lumbar spinal stenosis.
        Cochrane Database Syst Rev. 2016; (CD010264)
        • Hoffmann T.C.
        • Glasziou P.P.
        • Boutron I.
        • et al.
        Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
        BMJ. 2014; 348: g1687
        • Brox J.I.
        • Reikeras O.
        • Nygaard O.
        • et al.
        Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study.
        Pain. 2006; 122: 145-155
        • Brox J.I.
        • Sorensen R.
        • Friis A.
        • et al.
        Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration.
        Spine (Phila Pa 1976). 2003; 28: 1913-1921
        • Fairbank J.
        • Frost H.
        • Wilson-MacDonald J.
        • et al.
        Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial.
        BMJ. 2005; 330: 1233
        • Paker N.
        • Turkmen C.
        • Bugdayci D.
        • Tekdos D.
        • Erbil M.
        Comparison of conservative and surgical treatment results in lumbar spinal stenosis.
        Turk Neurosurg. 2005; 15: 182-184
        • Yu P.F.
        • Jiang F.D.
        • Liu J.T.
        • Jiang H.
        Outcomes of conservative treatment for ruptured lumbar disc herniation.
        Acta Orthop Belg. 2013; 79: 726-730
        • Peul W.C.
        • van den Hout W.B.
        • Brand R.
        • Thomeer R.T.
        • Koes B.W.
        Leiden-The Hague Spine Intervention Prognostic Study Group. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial.
        BMJ. 2008; 336: 1355-1358
        • Peul W.C.
        • van Houwelingen H.C.
        • van den Hout W.B.
        • et al.
        Surgery versus prolonged conservative treatment for sciatica.
        N Engl J Med. 2007; 356: 2245-2256
        • Peul W.C.
        • van Houwelingen H.C.
        • van der Hout W.B.
        • et al.
        Prolonged conservative treatment or 'early' surgery in sciatica caused by a lumbar disc herniation: rationale and design of a randomized trial.
        BMC Musculoskelet Disord. 2005; 6 ([ISRCT 26872154]): 8
        • Atlas S.J.
        • Deyo R.A.
        • Keller R.B.
        • et al.
        The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis.
        Spine (Phila Pa 1976). 1996; 21 (discussion 94-5): 1787-1794
        • Atlas S.J.
        • Deyo R.A.
        • Keller R.B.
        • et al.
        The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica.
        Spine (Phila Pa 1976). 1996; 21: 1777-1786
        • Atlas S.J.
        • Keller R.B.
        • Wu Y.A.
        • Deyo R.A.
        • Singer D.E.
        Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the Maine Lumbar Spine Study.
        Spine (Phila Pa 1976). 2005; 30: 936-943
        • Atlas S.J.
        • Keller R.B.
        • Wu Y.A.
        • Deyo R.A.
        • Singer D.E.
        Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study.
        Spine (Phila Pa 1976). 2005; 30: 927-935
        • Bridwell K.H.
        • Glassman S.
        • Horton W.
        • et al.
        Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study.
        Spine (Phila Pa 1976). 2009; 34: 2171-2178
        • Erginousakis D.
        • Filippiadis D.K.
        • Malagari A.
        • et al.
        Comparative prospective randomized study comparing conservative treatment and percutaneous disk decompression for treatment of intervertebral disk herniation.
        Radiology. 2011; 260: 487-493
        • Gerszten P.C.
        • Smuck M.
        • Rathmell J.P.
        • et al.
        Plasma disc decompression compared with fluoroscopy-guided transforaminal epidural steroid injections for symptomatic contained lumbar disc herniation: a prospective, randomized, controlled trial.
        J Neurosurg Spine. 2010; 12: 357-371
        • Hadzic E.
        • Dizdarevic K.
        • Hajdarpasic E.
        • Dzurlic A.
        • Ahmetspahic A.
        Low back and lumbar radicular syndrome: comparative study of the operative and non-operative treatment.
        Med Glas (Zenica). 2013; 10: 309-315
        • Hellum C.
        • Johnsen L.G.
        • Storheim K.
        • et al.
        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
        • Johnsen L.G.
        • Brinckmann P.
        • Hellum C.
        • Rossvoll I.
        • Leivseth G.
        Segmental mobility, disc height and patient-reported outcomes after surgery for degenerative disc disease: a prospective randomised trial comparing disc replacement and multidisciplinary rehabilitation.
        Bone Joint J. 2013; 95-B: 81-89
        • Malmivaara A.
        • Slatis P.
        • Heliovaara M.
        • et al.
        Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial.
        Spine (Phila Pa 1976). 2007; 32: 1-8
        • McMorland G.
        • Suter E.
        • Casha S.
        • du Plessis S.J.
        • Hurlbert R.J.
        Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study.
        J Manipulative Physiol Ther. 2010; 33: 576-584
        • Ohtori S.
        • Koshi T.
        • Yamashita M.
        • et al.
        Surgical versus nonsurgical treatment of selected patients with discogenic low back pain: a small-sized randomized trial.
        Spine. 2011; 36: 347-354
        • Osterman H.
        • Seitsalo S.
        • Karppinen J.
        • Malmivaara A.
        Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up.
        Spine (Phila Pa 1976). 2006; 31: 2409-2414
        • Slatis P.
        • Malmivaara A.
        • Heliovaara M.
        • et al.
        Long-term results of surgery for lumbar spinal stenosis: a randomised controlled trial.
        Eur Spine J. 2011; 20: 1174-1181
        • Veihelmann A.
        • Devens C.
        • Trouillier H.
        • Birkenmaier C.
        • Gerdesmeyer L.
        • Refior H.J.
        Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial.
        J Orthop Sci. 2006; 11: 365-369
        • Weinstein J.N.
        • Lurie J.D.
        • Tosteson T.D.
        • et al.
        Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis.
        N Engl J Med. 2007; 356: 2257-2270
        • Weinstein J.N.
        • Lurie J.D.
        • Tosteson T.D.
        • et al.
        Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort.
        JAMA. 2006; 296: 2451-2459
        • Weinstein J.N.
        • Lurie J.D.
        • Tosteson T.D.
        • et al.
        Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT).
        Spine (Phila Pa 1976). 2008; 33: 2789-2800
        • Weinstein J.N.
        • Lurie J.D.
        • Tosteson T.D.
        • et al.
        Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts.
        J Bone Joint Surg Am. 2009; 91: 1295-1304
        • Weinstein J.N.
        • Tosteson T.D.
        • Lurie J.D.
        • et al.
        Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial.
        Spine (Phila Pa 1976). 2010; 35: 1329-1338
        • Weinstein J.N.
        • Tosteson T.D.
        • Lurie J.D.
        • et al.
        Surgical versus nonsurgical therapy for lumbar spinal stenosis.
        N Engl J Med. 2008; 358: 794-810
        • Weinstein J.N.
        • Tosteson T.D.
        • Lurie J.D.
        • et al.
        Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial.
        JAMA. 2006; 296: 2441-2450
        • Lurie J.D.
        • Tosteson T.D.
        • Tosteson A.N.
        • et al.
        Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial.
        Spine (Phila Pa 1976). 2014; 39: 3-16
        • Zucherman J.F.
        • Hsu K.Y.
        • Hartjen C.A.
        • et al.
        A prospective randomized multi-center study for the treatment of lumbar spinal stenosis with the X STOP interspinous implant: 1-year results.
        Eur Spine J. 2004; 13: 22-31
        • Zucherman J.F.
        • Hsu K.Y.
        • Hartjen C.A.
        • et al.
        A multicenter, prospective, randomized trial evaluating the X STOP interspinous process decompression system for the treatment of neurogenic intermittent claudication: two-year follow-up results.
        Spine (Phila Pa 1976). 2005; 30: 1351-1358
        • Glasziou P.
        • Meats E.
        • Heneghan C.
        • Shepperd S.
        What is missing from descriptions of treatment in trials and reviews?.
        BMJ. 2008; 336: 1472-1474
        • Dijkers M.P.
        Reporting on interventions: issues and guidelines for rehabilitation researchers.
        Arch Phys Med Rehabil. 2015; 96: 1170-1180
        • Haskell W.L.
        • Lee I.M.
        • Pate R.R.
        • et al.
        Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association.
        Circulation. 2007; 116: 1081-1093
        • Hayden J.A.
        • van Tulder M.W.
        • Tomlinson G.
        Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain.
        Ann Intern Med. 2005; 142: 776-785
        • O'Sullivan P.B.
        • Phyty G.D.
        • Twomey L.T.
        • Allison G.T.
        Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis.
        Spine (Phila Pa 1976). 1997; 22: 2959-2967
        • Long A.
        • Donelson R.
        • Fung T.
        Does it matter which exercise? A randomized control trial of exercise for low back pain.
        Spine (Phila Pa 1976). 2004; 29: 2593-2602
        • van Tulder M.
        • Malmivaara A.
        • Esmail R.
        • Koes B.
        Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group.
        Spine (Phila Pa 1976). 2000; 25: 2784-2796
        • Rainville J.
        • Hartigan C.
        • Martinez E.
        • Limke J.
        • Jouve C.
        • Finno M.
        Exercise as a treatment for chronic low back pain.
        Spine J. 2004; 4: 106-115
        • O'Keeffe M.
        • Nolan D.
        • O'Sullivan P.
        • Dankaerts W.
        • Fersum K.
        • O'Sullivan K.
        Re: Aleksiev AR. Ten-year follow-up of strengthening versus flexibility exercises with or without abdominal bracing in recurrent low back pain.
        Spine (Phila Pa 1976). 2014; 39: E1495-E1497
        • Lu Y.
        • Guzman J.Z.
        • Purmessur D.
        • et al.
        Nonoperative management of discogenic back pain: a systematic review.
        Spine (Phila Pa 1976). 2014; 39: 1314-1324
        • van Benten E.
        • Pool J.
        • Mens J.
        • Pool-Goudzwaard A.
        Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review.
        J Orthop Sports Phys Ther. 2014; 44 (A1-15): 464-473
        • Fritzell P.
        • Hagg O.
        • Wessberg P.
        • Nordwall A.
        2001 Volvo Award Winner in Clinical Studies: lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.
        Spine (Phila Pa 1976). 2001; 26 (discussion 32-4): 2521-2532
        • Webster B.S.
        • Courtney T.K.
        • Huang Y.H.
        • Matz S.
        • Christiani D.C.
        Physicians' initial management of acute low back pain versus evidence-based guidelines. Influence of sciatica.
        J Gen Intern Med. 2005; 20: 1132-1135
        • Kwon B.
        • Katz J.N.
        • Kim D.H.
        • Jenis L.G.
        A review of the 2001 Volvo Award winner in clinical studies: lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.
        Spine (Phila Pa 1976). 2006; 31: 245-249