Skip to main content
Fusion surgery for mechanical axial low back pain

Fusion surgery for mechanical axial low back pain

Best Practice Guidance

How up to date is this information?

Published January 2020 | Last reviewed September 2024

Using this guidance

The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

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 surgery aims to stop movement at segment(s) of the spine to stabilise the joint and remove pain. Spinal fusion is not recommended for patients with isolated back pain where there is no identified cause.

This guidance applies to adults aged 19 years and over.

Recommendation

Spinal fusion surgery is not indicated for the treatment of isolated back pain i.e. pain which is localised to the back and not present in lower limbs, unless the following criteria are met:

  • Serious spinal pathology (for example, neoplasms, infections or osteoporotic collapse)
  • Scoliosis surgery
  • Sacroiliac joint dysfunction

Spinal fusion is appropriate during spinal decompression surgery for nerve compression, 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 continuing activity with modification, weight loss, analgesia and screening patients who are at high risk of developing chronic pain (i.e. STaRT Back). Use a combined physical and psychological programme for the management of sub-acute and chronic low back pain e.g. Back Skills Training (BeST).

Rationale for recommendation

Isolated back pain is common, often multifactorial and amenable to multimodal non-operative treatment (e.g. lifestyle modifications, weight loss, analgesia, 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 changes. This can unnecessarily create health anxiety for some patients, where simple reassurance would otherwise usually suffice. The NHS has released information regarding MRI imaging for patients with isolated lower back pain..

By the nature of the description, isolated back pain, a focal site of pathology is often never found. In many cases, symptoms may be underpinned by a centralised pain disorder that exists outside of the spine.

In the absence of a focal structural pathology and concordant mechanical or neurological symptoms, there remains a distinct lack of high-quality evidence to support fusion of the spine as a treatment of isolated back pain.

NICE Guideline NG59 established formal, multidisciplinary consensus on the management of isolated back pain, 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 vertebrae of the back. Isolated lower back pain means pain caused by stress and strain on the spine. Spinal fusion surgery is not helpful for isolated lower back pain and may make the pain worse.

About the condition

Isolated lower back pain is a 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 lifestyle changes. Surgery is unlikely 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 isolated 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 isolated back pain.

What are the RISKS?

Spinal fusion surgery for isolated back pain is unlikely to improve your symptoms. 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 painkillers may also help. You can discuss alternatives, and what is best for you, with your doctor.

What if you do NOTHING?

Most back pain settles by itself. If the pain does not settle, further investigations may be required. However, for many people, periods of back pain may come and go throughout their life.

NHS UK - Back pain

2022

Make the most of your appointment using BRAN

Coding

WHEN (LEFT(Primary_Spell_Procedure,4) LIKE '%V38[23456]%'
OR LEFT(Primary_Spell_Procedure,4) LIKE '%V39[34567]%'
OR LEFT(Primary_Spell_Procedure,4) LIKE '%V404%') 
AND Primary_Spell_Diagnosis LIKE '%M54[34589]%' 
AND NOT ( Any_Spell_Diagnosis LIKE '%M40[012]%' 
OR Any_Spell_Diagnosis LIKE '%M41[01234589]%' 
OR Any_Spell_Diagnosis LIKE '%M42[019]%' 
OR Any_Spell_Diagnosis LIKE '%M43[01589]%'
OR Any_Spell_Diagnosis LIKE '%M45%'
OR Any_Spell_Diagnosis LIKE '%C41[24]%'
OR Any_Spell_Diagnosis LIKE '%M462%'
OR Any_Spell_Diagnosis LIKE '%M533%'
OR Any_Spell_Diagnosis LIKE '%M80[01234589]8%'
)
-- Age between 19 and 120
AND ISNULL(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 
-- Only Elective Activity
AND APCS.Admission_Method not like ('2%') 
THEN '2Y_back_pain_fusion'
Exclusions
WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%' 
AND Any_Spell_Diagnosis not like '%D0%' 
AND Any_Spell_Diagnosis not like '%D3[789]%' 
AND Any_Spell_Diagnosis not like '%D4[012345678]%' 
OR Any_Spell_Diagnosis IS NULL)
-- 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]. 
  10. NICE. Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain. Interventional procedures guidance [IPG578]. 
  11. National Back Pain and Radicular Pain Pathway 1. (2017). Available at: https://www.ukssb.com/_files/ugd/dd7c8a_caf17c305a5f4321a6fca249dea75ebe.pdf. 
Also in this section
Back to top