Medical versus surgical treatment for low back pain: evidence and clinical practice.

CONTEXT Although low back pain is one of the most common health problems, it is still difficult to choose between surgical and medical treatment. OBJECTIVE To examine the evidence of the efficacy of surgical and medical treatment of the two most common indications for spinal surgery for low back pain--lumbar disc herniation and spinal stenosis--and to assess geographic variation in the use of surgery for these conditions in the United States. METHODS The MEDLINE database (1966-1999) was searched for all studies that compared surgical and medical treatments for low back pain. Data from the Health Care Financing Administration were used to examine geographic variation in spinal surgery rates for patients enrolled in Medicare (1996-1997). RESULTS Eight observational studies and one randomized clinical trial were identified. In general, these studies suggest better short-term outcomes (e.g., functional status and employability) with surgery than with medical approaches, but they indicate that long-term results are similar with both types of treatment. Methodologic flaws in the observational studies, particularly selection bias, preclude definitive conclusions about relative efficacy. In 1996 and 1997, more than 98,000 Medicare enrollees had surgery for disc herniation or spinal stenosis. Among hospital referral regions, rates of surgery for disc herniation varied 8-fold, from 0.24 to 1.96 per 1000 Medicare enrollees, and rates of surgery for spinal stenosis varied 12-fold, from 0.29 to 3.34 per 1000 Medicare enrollees. CONCLUSIONS The literature comparing the efficacy of surgical and medical treatment for low back pain is limited. Not surprisingly, the use of surgery for low back pain varies widely across the United States. To establish clinical consensus, we need better evidence about the efficacy of surgery.