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Fusion surgery for mechanical axial low back pain

Fusion surgery for mechanical axial low back pain

Best Practice Guidance

Summary

Spinal fusion is when two individual spinal vertebrae become joined together by bone formed as a result of surgery. This may involve the use of bone graft and/or surgical implants. The aim of the surgery is to stop motion at that joint in order to stabilise the joint. Spinal fusion is not recommended for patients with non-specific, mechanical back pain.

 

This guidance applies to adults aged 19 years and over.

Recommendation

Spinal fusion is not indicated for the treatment of non-specific, mechanical back pain. The NICE exclusion criteria are:

  • Conditions of a non-mechanical nature, including:
    • inflammatory causes of back pain (for example, ankylosing spondylitis or diseases of the viscera)
    • serious spinal pathology (for example, neoplasms, infections or osteoporotic collapse)
    • scoliosis
    • Pregnancy-related back pain
    • Sacroiliac joint dysfunction
    • Adjacent-segment disease
    • Failed back surgery syndrome
    • Spondylolisthesis.

Instead, spinal fusion is usually reserved for:

  • Patients with a symptomatic spinal deformity (e.g. scoliosis)
  • Instability (e.g. spondylolisthesis; trauma)
  • An adjunct during spinal decompression surgery, where a more extensive exposure of the affected neurological structures is required and would otherwise render the spine unstable.

Primary care management typically includes reassurance, advice on continuation of activity with modification, weight-loss, analgesia, manual therapy and screening patients who are high risk of developing chronic pain (i.e. STaRT Back). Use combined physical and psychological programme for management of sub-acute and chronic low back pain e.g. Back Skills Training (BeST).

Rationale for recommendation

Mechanical low-back pain is common, often multifactorial and amenable to multimodal non-operative treatment (e.g. lifestyle modifications, weight loss, analgesia, manual therapy, exercise). Imaging (e.g. plain film radiographs, MRI) in the absence of focal neurology (e.g. sciatica) or ‘red-flags’ may identify incidental, if not trivial, findings of age-related ‘wear and tear’ which can unnecessarily create a health-anxiety for some patients, where simple reassurance would otherwise usually suffice.

By the nature of the description ‘non-specific low back pain,’ a focal site of pathology is usually never found. In many cases, symptoms may be underpinned by a centralised pain disorder that exists outside the spine.

In the absence of a focal structural pathology (see above) and concordant mechanical or neurological symptoms, there remains a distinct lack of highquality evidence to support fusion of the spine as a treatment of mechanical axial back pain. NICE Guideline NG59 established formal, multi-disciplinary consensus on the management of back pain, with which is implemented through the National Back Pain Pathway. This NICE-endorsed pathway offers all patients timely, evidence-based care for back pain.

Patient information

Information for Patients

Spinal fusion surgery (an operation) is where a piece of bone or surgical material is used to connect two individual vertebrae of the back together. Mechanical lower back pain means pain caused by stress and strain on the spine. Spinal fusion surgery is not helpful for mechanical lower back pain and may make the pain worse.

About the condition

Lower back pain is a very common condition and can affect a person’s quality of life. However, it is rarely caused by serious disease and will often improve over time or with some changes to lifestyle. Surgery very rarely helps to improve back pain and should only be performed in certain rare cases. Medical evidence tells us that spinal fusion surgery is not recommended for mechanical lower back pain

What are the BENEFITS of the surgery?

Experts agree that there is no clear benefit to performing spinal fusion surgery for most mechanical lower back pain.

What are the RISKS?

Spinal fusion surgery may not improve your symptoms and may make your back pain worse. Also, any surgery involves risks, including infection, bleeding, and how anaesthetics may affect you.

What are the ALTERNATIVES?

Continuing with day-to-day activities as much as possible can benefit many people. For some people, losing weight, physical exercise, physiotherapy and/or pain killers may also help. You can discuss alternatives, and what is best for you, with your doctor.

What if you do NOTHING?

Most back pain often settles by itself. However, for many people, periods of back pain may come and go throughout their life.

Download this information

NHS UK - Back pain

2022

Make the most of your appointment using BRAN

Coding

Code Script

WHEN ( left(der.Spell_Dominant_Procedure,4) like '%V38[23456]%’
OR left(der.Spell_Dominant_Procedure,4) like '%V39[34567]%’
OR left(der.Spell_Dominant_Procedure,4) like '%V404%’ ) 
AND der.Spell_Primary_Diagnosis like '%M54[34589]%’ 
AND not (apcs.der_diagnosis_all like '%M40[012]%’ 
OR apcs.der_diagnosis_all like '%M41[01234589]%’ 
OR apcs.der_diagnosis_all like '%M42[019]%’ 
OR apcs.der_diagnosis_all like '%M43[01589]%’
OR apcs.der_diagnosis_all like '%M45%’
OR (apcs.der_diagnosis_all like '%O268%’ 
AND (apcs.der_diagnosis_all like '%M533%’ 
OR apcs.der_diagnosis_all like '%M54[345]%’) ) )
AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 
AND APCS.Admission_Method not like ('2%’) 
THEN '2Y_back_pain_fusion'

Code Definitions

Procedure codes (OPCS)

V382 Primary posterior interlaminar fusion of joint of lumbar spine
V383 Primary posterior fusion of joint of lumbar spine NEC
V384 Primary intertransverse fusion of joint of lumbar spine NEC
V385 Primary posterior interbody fusion of joint of lumbar spine
V386 Primary transforaminal interbody fusion of joint of lumbar spine
V393 Revisional posterior interlaminar fusion of joint of lumbar spine
V394 Revisional posterior fusion of joint of lumbar spine NEC
V395 Revisional intertransverse fusion of joint of lumbar spine NEC
V396 Revisional posterior interbody fusion of joint of lumbar spine
V397 Revisional transforaminal interbody fusion of joint of lumbar spine
V404 Posterior instrumented fusion of lumbar spine NEC

Diagnosis codes (ICD)

Inclusion
M543 Sciatica
M544 Lumbago with sciatica
M545 Low back pain
M548 Other dorsalgia
M549 Dorsalgia, unspecified
Exclusion
M400 Postural kyphosis
M401 Other secondary kyphosis
M402 Other and unspecified kyphosis
M410 Infantile idiopathic scoliosis
M411 Juvenile idiopathic scoliosis
M412 Other idiopathic scoliosis
M413 Thoracogenic scoliosis
M414 Neuromuscular scoliosis
M415 Other secondary scoliosis
M418 Other forms of scoliosis
M419 Scoliosis, unspecified
M420 Juvenile osteochondrosis of spine
M421 Adult osteochondrosis of spine
M429 Spinal osteochondrosis, unspecified
M430 Spondylolysis
M431 Spondylolisthesis
M435 Other recurrent vertebral subluxation
M438 Other specified deforming dorsopathies
M439 Deforming dorsopathy, unspecified
M45X Ankylosing spondylitis
O268 Other specified pregnancy-related conditions
M533 Sacrococcygeal disorders, not elsewhere classified*
M543 Sciatica*
M544 Lumbago with sciatica*
M545 Low back pain*
* Secondary to O268

Additional Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and 
apcs.der_diagnosis_all not like '%D0%' and 
apcs.der_diagnosis_all not like '%D3[789]%' and
apcs.der_diagnosis_all not like '%D4[012345678]%’

This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’

References

  1. NICE Guidelines (2016) Low back pain and sciatica in over 16s: assessment and management [NG59].
  2. National Low Back and Radicular Pain Pathway 2017: Improving spinal care project
  3. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Chau R et al. Spine (Phila Pa 1976). 2009 May 1;34(10):1094-109. doi: 10.1097/BRS.0b013e3181a105fc.
  4. Nice Guideline (2016) Low back pain and sciatica in over 16s: assessment and management [NG59] endorse STarT Back resource.
  5. Back Skills Training (BeST): Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost effectiveness analysis. Prof Sarah E Lamb DPhil et al on behalf of the Back Skills Training Trial investigators: https://doi.org/10.1016/S0140-6736(09)62164-4.
  6. Evidence for surgery in degenerative lumbar spine disorders. Jacobs WC et al. Best Pract Res Clin Rheumatol. 2013 Oct;27(5):673-84. doi: 10.1016/j. erh.2013.09.009. Epub 2013 Oct 5.
  7. https://choosingwiselycanada.org/spine/.
  8. NICE Clinical guidelines (2014) Neuropathic pain in adults: pharmacological management in non-specialist settings [CG173].
  9. NICE Published guidance (2011) Transaxial interbody lumbosacral fusion [IPG 387].

How up to date is this information?

Last revised December 2023

Changes

December 2023 - Coding updated. August 2022 - Coding updated

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