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Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain
  1. Jens Ivar Brox1,
  2. Øystein P Nygaard2,
  3. Inger Holm3,
  4. Anne Keller4,
  5. Tor Ingebrigtsen5,
  6. Olav Reikerås6
  1. 1Orthopaedic Department, Oslo University Hospital – Rikshospitalet, Oslo, Norway
  2. 2Neurosurgical Department, St Olavs Hospital, Trondheim, Norway
  3. 3Clinic of Rehabilitation, Oslo University Hospital – Rikshospitalet, Oslo, Norway
  4. 4Department of Physical Medicine and Rehabilitation, Oslo University Hospital – Ullevaal, Oslo, Norway
  5. 5Neurosurgical Department, University Hospital of North Norway, Tromsø, Norway
  6. 6Hospital of Rehabilitation, Stavern and Unifob Health, University of Bergen, Bergen, Norway
  1. Correspondence to Dr Jens Ivar Brox, Orthopaedic Department, Oslo University Hospital-Rikshospitalet, Sognsvannsveien, 0027 Oslo, Norway; jens.ivar.brox{at}


Objectives To compare the long-term effectiveness of surgical and non-surgical treatment in patients with chronic low back pain.

Methods Two merged randomised clinical trials compared instrumented transpedicular fusion with cognitive intervention and exercises in 124 patients with disc degeneration and at least 1 year of symptoms after or without previous surgery for disc herniation. The main outcome measure was the Oswestry disability index.

Results At 4 years 14 (24%) patients randomly assigned to cognitive intervention and exercises had also undergone surgery. 15 (23%) patients assigned fusion had undergone re-surgery. The mean treatment effect for the primary outcome was 1.1; 95% CI −5.9 to 8.2, according to the intention-to-treat analysis and −1.6; 95% CI −8.9 to 5.6 in the as-treated analysis. There was no difference in return to work.

Conclusions Long-term improvement was not better after instrumented transpedicular fusion compared with cognitive intervention and exercises.

Statistics from


  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the Ethics Committee Health region I, Norway.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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