Controversies in Management: The case for spinal fusion is unproved

Back pain affects about 80% of the population at some time in their life, and it is generally agreed that most people are best treated conservatively. Most episodes of acute back pain will settle either spontaneously or with treatment, but in a few people the pain does not resolve and they may be considered for spinal fusion.

Spinal fusion was originally developed for the treatment of tuberculosis, poliomyelitis, and scoliosis. Because it seemed successful for treating back pain arising from these conditions, it was assumed that any mechanical back pain could be successfully treated with spinal fusion. More than 20000 lumbar spinal fusions are performed annually in the United States, and there is a direct relation between the number of spinal operations performed in any one area and the number of orthopaedic and neurosurgeons.1 About eight times as many spinal surgical procedures are carried out in the United States per capita as in Britain.