Fusion surgery for mechanical axial low back pain
Best Practice Guidance
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.
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)
- Pregnancy-related back pain
- Sacroiliac joint dysfunction
- Adjacent-segment disease
- Failed back surgery syndrome
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.
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.
- 41 episodes during 2018/19
- Age/sex std rate per 100,000 – 0.1
- Reduction opportunity based on 25th percentile of activity across CCGs: not calculated.
- Variation (age/sex std rates):
- N-fold – 4.5
- 10th percentile – 0.1
- 25th percentile – 0.1
- 50th percentile – 0.3
- 90th percentile – 0.5
V38.2 Primary posterior interlaminar fusion of joint of lumbar spine
V38.3 Primary posterior fusion of joint of lumbar spine NEC
V38.4 Primary intertransverse fusion of joint of lumbar spine NEC
V38.5 Primary posterior interbody fusion of joint of lumbar spine
V38.6 Primary transforaminal interbody fusion of joint of lumbar spine
V40.4 Posterior instrumented fusion of lumbar spine NEC
M54.5 Low back pain
M54.9 Dorsalgia, unspecified
M87.2 Osteonecrosis due to previous trauma
M40.1Other secondary kyphosis
M40.2Other and unspecified kyphosis
M41.0Infantile idiopathic scoliosis
M41.1Juvenile idiopathic scoliosis
M41.2Other idiopathic scoliosis
M41.5Other secondary scoliosis
M41.8Other forms of scoliosis
M42.0 Juvenile osteochondrosis of spine
M42.1 Adult osteochondrosis of spine
M42.9 Spinal osteochondrosis, unspecified
M43.5 Other recurrent vertebral subluxation
M43.8 Other specified deforming dorsopathies
M43.9 Deforming dorsopathy, unspecified
(Note – cancer diagnoses are a global exclusion)
Any other criteria (e.g. patient age)
Adult (aged >=19 years)
Exclude any patients admitted as a non-elective admission
Will the procedure be carried out in OP or as APC?
Admitted Patient Care
Where the procedure code in dominant position is:
The diagnosis code in primary position is:
Any diagnosis code in any position is NOT:
Patient age >= 19 years
APCS.Admission_Method not like (‘2%’)
WHEN (left(der.Spell_Dominant_Procedure,4) like '%V38%' OR left(der.Spell_Dominant_Procedure,4) like '%V404%') AND der.Spell_Primary_Diagnosis like '%M54%' AND apcs.der_diagnosis_all not like '%M40%' AND apcs.der_diagnosis_all not like '%M41%' AND apcs.der_diagnosis_all not like '%M42%' AND apcs.der_diagnosis_all not like '%M43%' AND apcs.der_diagnosis_all not like '%M872%' 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'
Global cancer exclusion
APC WHERE 1=1 -- Cancer Diagnosis Exclusion AND (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%' AND apcs.der_diagnosis_all not like '%D4%' OR apcs.der_diagnosis_all IS NULL)
-- Private Appointment Exclusion AND apcs.Administrative_Category<>'02'
- NICE Guidelines (2016) Low back pain and sciatica in over 16s: assessment and management [NG59].
- National Low Back and Radicular Pain Pathway 2017: Improving spinal care project
- 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.
- Nice Guideline (2016) Low back pain and sciatica in over 16s: assessment and management [NG59] endorse STarT Back resource.
- 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.
- 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.
- NICE Clinical guidelines (2014) Neuropathic pain in adults: pharmacological management in non-specialist settings [CG173].
- NICE Published guidance (2011) Transaxial interbody lumbosacral fusion [IPG 387].
How up to date is this information?
August 2022 - Coding updated